Incident Response Plan

Transcription

1 Document Summary This plan sets out the Trust s generic response to both critical incidents and emergencies, detailing: roles and responsibilities; notification of such events; plan activation; command, control, communications and co-ordination; liaison with Trust stakeholders including partner agencies; and recovery arrangements. DOCUMENT NUMBER DATE RATIFIED POL/002/073 DATE IMPLEMENTED September 2017 NEXT REVIEW DATE September 2018 ACCOUNTABLE DIRECTOR POLICY AUTHOR 18 October 2017 Director of Quality & Nursing Resilience Manager Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and, as such, may not necessarily contain the latest updates and amendments. IN THE EVENT OF AN IMMEDIATE THREAT, FOLLOW THE FLOWCHART ON PAGE 2. IF THIS PLAN IS ACTIVATED BY AN EXECUTIVE DIRECTOR Please read the relevant section(s) in the plan relating to the incident and/or relevant action card at APPENDIX L (page 71 onwards). Please do not use landline phones or lifts unless absolutely necessary. If off-duty, please do not phone to ask if you are required. Please either wait at a specified location or wait to be called in. All staff not involved in response activities should continue with their normal duties. 9 October 2017 (Version 5.11) Page 1 of 113 Our Ref: CO/POL/002/073

2 Incident Occurs Threat to Staff or Visitors No During office hours, notify Line Manager or BC Lead. Out of hours notify the relevant BRONZE on Start Incident Log Yes Dial 999 for Emergency Services, then notify Line Manager Line Manager/BC Lead/Senior member of staff on duty Account for all staff on duty (including contractors or Visitors) and maintain their safety and wellbeing until the Emergency Services arrive No Line Manager/BC Lead: Assess nature and impact against Business Continuity Incident Identification Matrix (See Page 3) Green Incident? Update relevant tactical and operational BCPs Processes and Procedures Yes Line Manager/BC Lead: Manage incident, monitor for possible escalations. Inform line manager when the situation resolves or deteriorates Complete Electronic Incident Report Notify plan owner and Resilience Manager No (AMBER OR RED) SIGNIFICANT INCIDENT OR EMERGENCY Provide a situation report to the line Manager (Out of hours notify the Bronze immediately on ) stating: Type of Incident Current and anticipated impacts of incident Any casualties Any decisions/actions taken Any recommendations (extra help or resources required) Level of media interest Which other partners or agencies are involved Any other relevant information Confirm that all these points will be recorded in an incident log book (Keep any trigger notes) Monitor, Review and escalate if necessary Recovery time Objective (RTO) = Period of time following an incident within which the service/activity MUST be recovered or resources MUST be recovered No Escalation to relevant Bronze? Update Incident Log Affects a prioritised activity? Consider Business Continuity Response (Immediate BCM Actions on Page 3) Business Continuity Director: Activate the Corporate Business Continuity Plan and convene the Business Continuity Management group Yes Do Tactical BCPs need activating? Yes Yes RTO 0-24 hours? Yes Do Operational BCPs need activating? Yes Executive Director/ Senior Manager: Activate Operational BCP Affects a number of Prioritised activities? No No No Yes Inform and Follow instructions from relevant Bronze (Incident response team or central incident response team) until Stand Down Message is issued Monitor for possible escalation and advise line manager or relevant Bronze accordingly. Out of hours, Bronze to escalate to Silver if necessary STAND DOWN Recovery 1: Debrief report 2: Action Plan 3: Incident Log No Hold a post incident review within 28 days (Internal) Hot Debrief conducted by Resilience Manager within 24 hours or as soon as practicable to include plan owner and staff involved in the incident/disruption Post Incident Report Update relevant tactical and operational BCPs, Processes and Procedures Normal Service Resumes 9 October 2017 (Version 5.11) Page 2 of 113 Our Ref: CO/POL/002/073

3 TABLE OF CONTENTS 1.0 SCOPE INTRODUCTION STATEMENT OF INTENT Aims Priorities DUTIES Chief Executive Medical Director Caldicott Guardian Senior Information Risk Officer (SIRO) Director of Quality & Nursing Deputy Director of Operations Associate Director for Corporate Governance and Company Secretary Head of Engagement and Communications Associate Directors of Operations/Heads of Service Senior Network Managers Infection prevention lead Lead pharmacist Head of Information Professional Head of Estates and Facilities Manager Resilience Manager Trust staff, including seconded, bank and agency staff Resilience Group KEY ROLES AND RESPONSIBILITIES Incident Director (CPFT Gold) Incident Controller(s) (CPFT Silver(s)) CPFT Bronze commanders (Community Services and Mental Health) Trust staff asked to respond to a critical incident or emergency Incident response team(s) Communications lead ALERTING Triggers During normal working hours Out of hours External alerts PLAN ACTIVATION Initial risk assessment Safety Triggers for Emergency Personnel (STEP 123 Plus) for incidents which potentially may involve hazardous materials (HAZMAT)) Non-activation of the INCIDENT RESPONSE Levels of commands INCIDENT CO-ORDINATION CENTRES INCIDENT MANAGEMENT BY COMMUNITY SERVICES District/community nurses Alerting district/community nurses Deploying district/community nurses Alerting community hospitals and minor injuries units COMMAND, CONTROL, COMMUNICATIONS AND CO-ORDINATION (4C) CPFT Incident Director (CPFT GOLD) CPFT Incident Controller(s) (CPFT Silver(s)) Multi-agency command & control structure (acute/response phase) Strategic Co-ordinating Group (SCG) Science and Technical Advisory Cell (STAC) Recovery Co-ordinating Group (RCG) Tactical Co-ordinating Group (TCG) Multi-agency media cell Tactical health cell Operational Co-ordinating Group (OCG) COMMUNICATIONS DURING A CRITICAL INCIDENT OR EMERGENCY MAJOR IT/TELECOMMUNICATIONS/POWER DISRUPTION ESCALATION AND DE-ESCALATION SAFETY & WELFARE Lone working Personal protective equipment Safety cordons Rendezvous point (RVP) Slips, trips and falls 29 9 October 2017 (Version 5.11) Page 3 of 113 Our Ref: CO/POL/002/073

4 11.0 SUSTAINABILITY AND HANDOVER MANAGEMENT OF STAFF DURING A CRITICAL INCIDENT OR EMERGENCY Changing working hours Staff maintaining contact with line manager Redeployment Cancelling or suspending scheduled meetings and training SECURITY MAINTAINING BUSINESS CONTINUITY INFORMATION TECHNOLOGY (IT) RESILIENCE VULNERABLE PATIENTS AND STAFF CRITICAL INCIDENTS OR EMERGENCIES INVOLVING CHILDREN AND YOUNG PEOPLE CULTURAL, RELIGIOUS AND DIVERSITY ISSUES MANAGEMENT OF PUBLIC HEALTH INCIDENTS MULTIPLE OR MASS CASUALTY INCIDENTS MANAGEMENT OF BURN-INJURED PATIENTS PROVISION OF HEALTHCARE SERVICES AT REST CENTRES CROWD BEHAVIOUR FIREARMS AND WEAPONS ATTACKS HAZARDOUS MATERIALS (HAZMAT) OR CHEMICAL, BIOLOGICAL, RADIOLOGICAL, NUCLEAR AND EXPLOSIVES (CBRNE) INCIDENTS LOCKDOWN CATASTROPHIC INCIDENTS ADMINISTRATION Legal implications Protective marking of information Information sharing Logging messages Briefings Situation reporting (BLANK TEMPLATE - APPENDIX E) Documentation Loggists Documentary evidence Incident recordings (audio and video) Forensic evidence MUTUAL AID ARRANGEMENTS STAND DOWN DEBRIEFING/LESSONS IDENTIFIED Hot debriefs Cold/multi-agency debriefs SERIOUS UNTOWARD INCIDENTS PSYCHOSOCIAL SUPPORT RECOVERY PROCUREMENT AND FINANCIAL ARRANGEMENTS CRITICAL EQUIPMENT AND CONSUMABLES PLAN MAINTENANCE AND REVIEW DISTRIBUTION OF PLAN TRAINING & EXERCISES FREEDOM OF INFORMATION ACT 2000 (FOIA) AND ENVIRONMENTAL INFORMATION REGULATIONS 2004 (EIR) REQUESTS HUMAN RIGHTS MONITORING COMPLIANCE WITH THIS DOCUMENT. 45 REFERENCES/ BIBLIOGRAPHY 45 APPENDIX A ESCALATION OF INCIDENTS TO NHS ENGLAND NORTH (CUMBRIA AND THE NORTH EAST) 50 APPENDIX B NOTIFICATION OF AN INTERNAL CRITICAL INCIDENT OR EMERGENCY 51 Table 1: (Business continuity) incident levels.. 52 APPENDIX C NOTIFICATION CASCADE OF AN EXTERNAL MAJOR INCIDENT.. 53 APPENDIX D METHANE FORM.. 54 APPENDIX E INCIDENT SITUATION REPORT (SITREP). 55 APPENDIX F CPFT GOLD (STRATEGIC) INCIDENT COMMANDER HANDOVER FORM. 58 APPENDIX G SUGGESTED 1 st MEETING AGENDA OF AN INCIDENT RESPONSE TEAM. 61 APPENDIX H SIGNAGE TEMPLATE. 62 APPENDIX I DEFINITIONS.. 63 APPENDIX J DECISION-MAKING MODEL (JOINT DECISION MODEL) & STEEPLE ANALYSIS 69 APPENDIX K CPFT GOLD STRATEGY 70 APPENDIX L RED-COLOURED ACTION CARDS.. 71 RECORD OF AMENDMENTS. 111 ABBREVIATIONS October 2017 (Version 5.11) Page 4 of 113 Our Ref: CO/POL/002/073

5 1.0 SCOPE 1.1 This document applies to all services, activities and staff (exception stated in section 1.8 below) within Cumbria Partnership NHS Foundation Trust (hereinafter referred to as the Trust or CPFT ). 1.2 The plan sets out a broad framework for a generic response to a critical incident or emergency in a multi-agency context including emergencies with an identifiable scene as well as managing wide-area emergencies. This plan also notes the possibility that a future incident may have a number of individual scenes requiring, for example, multiple CPFT Silver(s) (tactical commanders), or possibly having no actual scene, for example, a maritime incident. 1.3 The terms major incident and emergency will be used interchangeably throughout this document relevant definitions are set out in APPENDIX I. Similarly NHS England s Emergency Preparedness, Resilience and Response (EPRR) is synonymous with the term emergency planning. The terms critical incident and emergency are deliberately broad to ensure that potential incidents are not missed. A critical incident can be described as any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions. The term patient will refer to any individual (service user, client) accessing Trust services. NHS England - North (Cumbria and the North East) will be abbreviated as CNE. Presentational conventions observed in this document include: the word must is used to express necessity and is shown in red block capitals and underlined for emphasis. The word should is used to express recommendations, the word may is used to express permissibility and the word can is used to express possibility. The interchangeable use of shall and will is an acceptable part of standard British English. 1 The word not is underlined purely for emphasis. To highlight the possibility that an incident might necessitate having a number of silver (tactical) commanders as might be the case with partner agencies, the term CPFT Silver(s) is used. Where applicable multi-agency equivalent terms from the Joint Emergency Services Interoperability Programme (JESIP) for each tier of command will be written alongside the traditional health 3-tier command system (e.g. Gold (strategic), Silver (tactical), Bronze (operational) (GSB)). 1.4 This plan is not intended to be exhaustive or restrictive and does not preclude the innovative use of strategies, other plans which are lawful, human rights compliant and which have been adequately risk assessed. No plan can cover every eventuality, so it is crucial that staff use their professional judgement in dealing with any such incident. 1.5 Pandemic influenza, Stage 3 or 4 (i.e. building or site) evacuation and lockdown 2, heatwave and severe weather are dealt with in specific emergency plans, which supplement the information provided in this document. 1 The New Oxford Dictionary of English, p Whilst lockdown is a security-management responsibility, a number of plans detail evacuation and lockdown considerations in the same document to encourage flexibility of any response, hence some planning, training and exercising are delivered jointly by the relevant Local Security Management Specialist and the Resilience Manager. 9 October 2017 (Version 5.11) Page 5 of 113 Our Ref: CO/POL/002/073

6 1.6 Flexibility of approach and co-operation with partner agencies (e.g. Local Resilience Forum (LRF) colleagues) are recurrent themes, particularly when responding to an external emergency, where the assistance required may go beyond the Trust s day-to-day operational boundaries. This plan is also scalable as it can be applied to catastrophic incidents. 1.7 This plan may be activated to respond to internal incident(s) if the severity of the situation necessitates, but this decision MUST be always taken by an Executive Director. 1.8 Prison healthcare staff will come under the jurisdiction of Her Majesty s Prison Service (HMPS) contingency planning and as such this plan will not apply to those members of staff on site at HMP Haverigg at the time of an incident, but will remain valid for those members of the team working from another Trust facility for whatever reason. 1.9 The importance of public confidence and trust in the NHS response to any incident cannot be overstated. Some disruptive challenges encountered by the Trust do not necessarily lead to the activation of this plan. However a major incident may trigger associated business continuity disruption, which may have the potential to do more harm organisationally, financially and reputationally than the major incident itself. All departments and services are required to maintain comprehensive business continuity plans that safeguard critical functions (prioritised activities) during an emergency limited hardcopies should be held by services. Electronic copies of business continuity plans should be uploaded to local Sharepoint sites that are managed by the respective care group. Approved emergency and business continuity plans will also be held on the Resilience Portal This plan is the culmination of risk assessment: all Trust emergency and business continuity plans are risk-based drawing on, where applicable, the respective entry in the Cumbria Community Risk Register. Inclusion of a hazard or a particular scenario does not necessarily mean that a related incident will occur, or if it was to happen that it would be on that scale. Risk scenarios are based on reasonable worst-case assumptions. 2.0 INTRODUCTION 2.1 The Trust is required to prepare planning arrangements for a range of emergencies and the continuity of its critical functions on account of its community services are designated as a Category 1 responder under the Civil Contingencies Act The Civil Contingencies Act 2004 (CCA or the Act ) and accompanying non-legislative measures deliver a single framework for civil protection in the United Kingdom which comes in two parts: Part 1 sets out the roles and responsibilities of local organisations involved in emergency preparation and response; and Part 2 details emergency powers. 2.3 The main civil protection duties which fall on Category 1 responders are as follows: risk assessment; business continuity management (BCM); emergency planning; 9 October 2017 (Version 5.11) Page 6 of 113 Our Ref: CO/POL/002/073

7 maintaining public awareness and arrangements to warn, inform and advise the public Two further duties are prescribed in the Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005: co-operation and information sharing. 2.5 Emergency planning and business continuity management are two separate disciplines, but should be seen as being mutually reinforcing as it is crucial to consider the continuity of the Trust s critical functions if having to activate this plan. 2.6 This plan is based on the principles of integrated emergency management (IEM) and sets out: the basis for effective command & control that seeks to incorporate current good practice and guidance (e.g. NHS England s Emergency Preparedness Framework); the basis for an integrated response with health/lrf partners; a cohesive approach to situational awareness, risk assessment and decision-making at all levels of command (i.e. Gold (strategic), Silver (tactical), Bronze (operational); the roles and responsibilities of key staff dealing with a critical incident or emergency, including use of action cards; arrangements for the management of vulnerable Trust patients and staff; considerations to address the individual needs of Trust patients and staff; considerations for recovery from such an event(s) as soon as reasonably practicable. 2.7 Role-specific action cards serve as an aide-memoire to key staff performing duties during a critical incident or emergency and are found in the final appendix of this plan. Actions are not numbered as events are unlikely to occur any sequential order. Staff acting outside of their area of normal activity should be given specific instructions. The Chief Executive, CPFT Gold (strategic) and CPFT Silver (tactical) commanders will be issued with three copies of the laminated card (for infection control purposes) appropriate for their role on revision of this plan, which should be kept in a work desk drawer, work bag and any grab bag in their car boot other staff likely to be involved in incident response/recovery should produce their own copies of relevant action cards. Staff should carefully read these cards several times and ask questions if unclear on any aspects of their intended role. (NEVER STORE PERSONAL MEDICATION, WORK LAPTOP/TABLET OR CONFIDENTIAL INFORMATION IN A CAR BOOT). Permanent marker pens 4 can be used to annotate any trigger notes on laminated action cards. Any annotated action cards MUST be held securely with the corresponding personal log until requested by a competent authority (e.g. Cumbria Police or the Health and Safety Executive (HSE)). CHECK DATE/VERSION ON ACTION CARD PRIOR TO ATTENDING AN INCIDENT. For ease of identification all action cards relating to this plan will be coloured red and marked: RED-COLOURED ACTION CARD = (MAJOR) INCIDENT RESPONSE. 3 A fifth civil protection duty applies to local authorities: provision of advice and assistance to the commercial sector and voluntary organisations. 4 During inclement weather or if the incident involves some form of water damage to CPFT estate (e.g. internal flooding or firefighting water run-off) consider using wooden chinograph pens. Both fine-tipped marker pens and wooden chinograph pens should be purchased and distributed locally by care groups. 9 October 2017 (Version 5.11) Page 7 of 113 Our Ref: CO/POL/002/073

8 3.0 STATEMENT OF INTENT 3.1 The Trust will endeavour to respond to a critical incident or emergency as well as maintaining its civil protection duties as a Category 1 responder and contractual obligations as far as reasonably practicable. The Incident Director (CPFT Gold), Incident Controllers (CPFT Silver(s)) and the incident response team(s), and/or (strategic-level) business continuity management group (BCMG), and/or (tactical-level) central incident response team (CIST) are assisted in their decision-making by using planning prepared by the Trust, Cumbria Local Health Resilience Partnership (LHRP), Cumbria (Local) Resilience Forum (LRF), department/service/team business continuity plans, the decision-making model (APPENDIX J) and the CPFT Gold Strategy (APPENDIX K). 3.2 Aim To protect the Trust and its stakeholders, including patients, staff, visitors, contractors and local communities during a critical incident(s) or emergency where reasonably practicable. 3.3 Priorities Priorities are essential to create a cohesive strategy and tactical plans with multi-agency partners. These will indicate how available resources will be deployed in the most effective and efficient manner. +24 hours = counter immediate threat to life & co-ordinate emergency response; +72 hours = manage communications & infrastructure and care for patients/ vulnerable groups/displaced families/local communities; +30 days = oversee restoration of infrastructure and continue care for patients/ vulnerable groups/displaced families/local communities. 3.4 Strategic objectives (depending on incident) Instigate command, control, communications and co-ordination in respect of the incident. Protect the health, safety and welfare of patients, staff, visitors and contractors at Trust facilities or using its services. Maintain effective communications with CNE and health/lrf partners. Support CNE and health/lrf partners to preserve and protect life. Mitigate and minimise the impact of an incident. Warn and inform Trust stakeholders including the public. Identify vulnerable patients and staff. Evacuate patients and non-essential staff if applicable. Minimise the consequential disruption (impact and duration) to the Trust s critical clinical and management functions. Deliver humanitarian assistance and psychological first aid to victims of an emergency or a critical incident as directed by CNE. Safeguard the environment. Prevent unnecessary acute care admissions. Promote early-supported discharge of appropriate patients to increase local capacity. Assist an early return to normality (or as near to it as can be reasonably achieved). Facilitate judicial, public, technical, or other inquiries. Evaluate the response and recovery to the incident and identify issues and lessons. 9 October 2017 (Version 5.11) Page 8 of 113 Our Ref: CO/POL/002/073

9 3.5 CPFT shall: be signed-off by the Chief Executive and Accountable Emergency Officer; be approved by the Trust Board communicated to all staff working for and on behalf of the Trust; made available on Staff Web (Trust intranet) as a quick link ; reviewed at least annually, unless subject to legislative, organisational or other significant change. 4 DUTIES 4.1 This section outlines roles and responsibilities for relevant staff in respect of EPRR. 4.2 Chief Executive (Deputy Chief Executive) see action card at end of this plan Overall responsibility for ensuring the Trust has appropriate planning arrangements in place for emergency response and recovery. 4.3 Medical Director see action card at end of this plan Duties may include (during and after a critical incident or emergency but are not limited to): providing input into routine contingency planning; providing advice on clinical governance issues and addressing training needs of doctors; providing clinical support to CPFT Silver(s); ensuring effective measures are implemented to identify appropriate patients for discharge or transfer; ensuring medical staff take appropriate action during and after an incident; ensuring effective use of resources; communicating medical staffing requirements; and working with CPFT Silver(s) to develop/implement recovery plans for a safe and efficient restoration of normal levels of service. 4.4 Caldicott Guardian (Medical Director) Ensures the Trust achieves the highest practical standards for handling patient information. This includes representing and championing confidentiality requirements and issues at Board level, and where appropriate within the Trust s overall governance framework. During critical incidents/emergencies the Caldicott Guardian should advise on disclosure of information and be available to support staff. 4.5 Senior Information Risk Officer (SIRO) Responsible for: ensuring that there is an information risk policy and strategy in place; having responsibility for the risk assessment process of information risks; managing threats to security; ensuring that all employees are aware of their responsibilities; and keeps the Board informed of information risks. 4.6 Director of Quality and Nursing The Director of Quality & Nursing is CPFT Accountable Emergency Officer (AEO) and also has responsibility for resilience and business continuity arrangements for the on-call system for all operational services. Duties may include (before, during and after a critical incident or emergency but are not limited to): monitoring patient safety; supporting nursing staff performing their duties; identifying unresolved issues and pressures; escalating significant risks and other concerns to the Chief Executive and the Board; maintaining vigilance for significant loss or change in the quality of service; 9 October 2017 (Version 5.11) Page 9 of 113 Our Ref: CO/POL/002/073

10 increasing nursing capacity by mobilising teams in adjoining areas or using bank staff; undertake measures to safeguard staff welfare; ensuring business continuity arrangements are in place for their (functional or geographical) area(s) of responsibility. 4.7 Deputy Director of Operations Duties may include (before, during and after a critical incident or emergency but are not limited to): communicating this plan to clinical staff; developing and maintaining the Trust s strategic business continuity plan to protect its most critical clinical and management functions; defining the strategic response of clinical staff during normal business hours, including clear strategic aim and objectives and reviewing them regularly (out of hours (OOH) Gold); establishing a policy framework for the overall management of the event or situation; minimising the consequential disruption (impact and duration) affecting Trust critical clinical and management functions; ensuring operational processes and procedures are in place to support the safe and efficient restoration of normal levels of service; with the communications lead and multi-agency partners, formulating and implementing media-handling, public advice and communications; directing planning and operations beyond the immediate response in order to facilitate the recovery process. 4.8 Associate Director for Corporate Governance and Company Secretary Duties may include (before, during and after a critical incident or emergency but are not limited to): communicating this plan to Trust directorates and services; ensuring that the requirements of this plan are met by Trust directorates and services; ensuring the Director of Quality & Nursing (AEO) is kept informed of significant concerns in relation to Emergency Preparedness, Resilience and Response (EPRR) and business continuity management (BCM); ensuring EPRR and BCM are implemented throughout the Trust; embedding a business continuity culture throughout the Trust; assuming the role of emergency planning lead if the Resilience Manager is absent. 4.9 Head of Engagement and Communications (See section Communications lead and action card at end of this plan) Duties may include (before, during and after a critical incident or emergency but are not limited to): formulating media-handling and implementing communications plans; with an Executive Director s approval preparing and communicating key messages for patients, staff, and key stakeholders; instigating an effective cascade to Trust staff; co-ordinating media enquiries; relaying appropriate, accurate and timely updates to Trust patients, staff, carers and the wider public; developing agreed pre-prepared information for Staff Web, the Trust internet site and other authorised channels of communication; 9 October 2017 (Version 5.11) Page 10 of 113 Our Ref: CO/POL/002/073

11 ensuring business continuity arrangements are in place for their functional area(s) of responsibility Associate Directors of Operations/Heads of Service Duties may include (before, during and after a critical incident or emergency but are not limited to): communicating this plan to their staff; assessing the risks that might affect services within their area(s) of responsibility (functional, geographical and/or pertaining to hosted services); depending on the nature of the incident, co-ordinating a tactical response and monitoring its effectiveness; acting as the single conduit for communications between the care group/service and the incident response team(s); assuming overall ownership and co-ordination of crisis management and operational recovery for their (functional or geographical) area(s) of responsibility; developing and maintaining operational business continuity plans that protect essential service within their (functional or geographical) area(s) of responsibility; instructing their managers and team leads to take appropriate action if required to maintain critical clinical and management functions and the safety and wellbeing of patients, staff, visitors, and contractors; ensuring any significant service changes or risks are noted in relevant departmental risk registers and business continuity plans (and revised versions of BCPs are to be forwarded to the Resilience Manager); ensuring themselves and their staff are aware of their roles and responsibilities during the response and recovery phases of a critical incident, emergency or business continuity disruption; ensuring situation reports are produced and forwarded at agreed intervals; approved Trust messages are cascaded to staff (without immediate access to e- mail/staff Web); ensuring their own participation and that of their staff in related training and exercises arranged by, or including, the Trust; liaising with the Resilience Manager on matters pertaining to EPRR or BCM Senior Network Managers Duties may include (before, during and after a critical incident or emergency but are not limited to): communicating this plan, BC policy and relevant emergency/business continuity plans to staff, including new starters, seconded, bank and agency staff; providing an operational response during normal business hours (OOH CPFT Bronze Community Services or Mental Health North/South, whichever is appropriate); minimising the consequential disruption (impact and duration) affecting critical clinical functions within their (functional or geographical) area(s) of responsibility; ensuring operational processes and procedures are in place to support the safe and efficient restoration to normal levels of service; monitoring staff welfare; ensuring BCM is in place for their (functional or geographical) area(s) of responsibility. 9 October 2017 (Version 5.11) Page 11 of 113 Our Ref: CO/POL/002/073

12 4.12 Infection prevention lead (depending on nature of emergency) see action card at end of this plan Duties may include (before, during and after a critical incident or emergency but are not limited to): overseeing local compliance with infection control policies and procedures and their implementation; disseminating infection control guidance in accordance with that issued by the Department of Health, NHS England and PHE; supporting the raising awareness, education and training of Trust healthcare staff in measures to reduce the person-to-person spread of viruses; providing advice and support for Trust staff and contractors; liaising with other infection prevention leads on pandemic preparedness and infection control matters Lead pharmacist (depending on nature of emergency) Duties may include (before, during and after a critical incident or emergency but are not limited to): providing advice and guidance on business and service continuity issues in respect of the supply, safe storage and use of medication; ensuring business continuity arrangements are in place for their functional area(s) of responsibility Head of Information see action card at end of this plan Duties may include (before, during and after a critical incident or emergency but are not limited to): providing any necessary IT support (including IP and analogue telephony) to the incident response team(s) and/or (strategic-level) business continuity management group and/or (tactical-level) central incident support team (CIST) (if convened); assisting with resolving faults on IP and analogue telephony and IT equipment or in the incident co-ordination centre(s) if required and giving these the highest priority; assessing the risks that might affect critical Trust and shared IT infrastructure, and national and Trust applications; monitoring continuity of Trust critical IT applications and infrastructure including, paradoxically, air conditioning for key locations during winter conditions; considering suspension of all non-essential work by IT staff or third parties until stand down has been issued; assisting to bring critical IT applications and infrastructure at affected Trust sites back online in a safe, prioritised and controlled manner; ensuring adequate plans are in place for the recovery of Trust or shared (or outsourced) infrastructure and applications; minimising the consequential disruption (impact and duration) affecting Trust s critical IT services; develop, implement and maintain a mesh of interdependent activities, so that cyber resilience and security integrates: staff/partners, IT/technical and information, detection, investigation and learning elements from across the organisation; ownership of relevant policies, plans, including the disaster recovery plan(s) and activities to ensure IT resilience; ensuring appropriate plans, procedures, systems and processes are in place to minimise 9 October 2017 (Version 5.11) Page 12 of 113 Our Ref: CO/POL/002/073

13 the likelihood/impact of a threat to the Trust through the loss of, or underperformance or some other form of default by a third party IT contractor or supplier; activation of disaster recovery plan(s) and BC arrangements for IT services; providing technical assets to allow a prioritised return to work following business continuity disruption for staff delivering critical functions; facilitating appropriate supplier and/or other third-party support, including disaster recovery during and after business continuity disruption affecting the Trust s IT applications/systems Professional Head of Estates (see action card at end of this plan entitled: Estates Manager or on-call Estates Manager ) and Facilities Managers Duties may include (before, during and after a critical incident or emergency but are not limited to): maintaining their own business continuity plans for the scope of Estates and Facilities activities; liaising with landlords and contractors to aid the Trust s ability to maintain or recover its infrastructure 4.16 Resilience Manager Duties may include (before, during and after a critical incident or emergency but are not limited to): ensuring arrangements for EPRR and BCM are kept under regular review; the development and implementation of the Trust s BCM programme; advising on compliance of the Trust s community services with respect to the CCA regime; ensuring that EPRR and IT resilience are co-ordinated in conjunction with the Trust s BC policy; providing awareness raising and training to staff appropriate for their roles and needs; audit compliance of business continuity plans; facilitating tests and exercising key aspects of EPRR and BCM; providing recommendations and other management feedback as appropriate Trust staff, including seconded, bank and agency staff All staff are responsible for (but not limited to) ensuring that they: understand this plan and are aware of any possible specific roles and responsibilities relevant for their post; know where to access a controlled version of this plan (i.e. Staff Web); keep up-to-date when any changes are made; participate in the preparation, testing, exercising and review of this plan where appropriate. NOTE: Non-Executive Directors have no role in the management of any incident but will be kept informed along with other CPFT staff Resilience Group The Resilience Group will ensure that EPRR and BCM are implemented, co-ordinated, reviewed, and tested across all directorates and promotion of a business continuity culture throughout the Trust. 9 October 2017 (Version 5.11) Page 13 of 113 Our Ref: CO/POL/002/073

14 5.0 KEY ROLES AND RESPONSIBILITIES 5.1 Incident Director (CPFT Gold) see action card at end of this plan During a critical incident or emergency the duties of the nominated Executive Director during his/her shift may include, but are not limited to, the following: ensure his/her work mobile phone is switched on and functioning; serve as first point-of-contact for all external incident alerts; authenticate and confirm an incident alert with CNE on-call manager/director or partner agency representative; put the Trust at Major Incident STANDBY or Major Incident DECLARED if deemed appropriate; if internal event/disruption, decide to declare an internal critical incident and/or business continuity incident; activate the Trust s (and other emergency and business continuity plans as appropriate); initiate a callout of key staff to form an incident response team(s); oversee continuity of the Trust s critical clinical and management functions; notify the Chief Executive; inform and involve relevant authorities; agree the strategic aim and objectives for the Trust s response to and recovery from the incident. maintain full direction and control over Trust staff; conduct shared (i.e. with multi-agency partners), ongoing risk assessment ongoing risk assessment and management in response to the dynamic nature of the incident; obtain and provide technical and professional advice from suitable sources to inform decision-making where required; understand the principle of a duty of care applies across all responding agencies; understand the roles and responsibilities of all responding organisations including broad structures, methods of communication and decision-making processes; understand the culture, priorities and constraints of partner organisations; understand the relevant incident response plans and arrangements including predetermined procedures for involvement of other organisations; establish the strategic and policy framework within which Incident Controller(s) (CPFT Silver(s) will work; review the effectiveness of the strategy and updating or varying the strategy in response to changing situations or information (see APPENDIX K); identify factors relevant to setting and reviewing the strategy including shared ongoing risk assessment, community impact, and the longer-term recovery process; appreciate the importance of operational intelligence and its dissemination to all relevant staff through briefings; understand the purpose and importance of recording incident information and how this information should be retained; sign-off log(s), all briefing papers and other documents relating to the incident; determine whether legal advice is required to inform decision-making; understand the role and responsibilities of lead responders for warning and informing and Trust and LRF media protocols; have an awareness of the potential operational implications of critical incidents (e.g. longterm recovery or wide-area issues); have an awareness of the potential impact of critical incidents on the environment; 9 October 2017 (Version 5.11) Page 14 of 113 Our Ref: CO/POL/002/073

15 assess the short- and long-term human impact of critical incidents and identify the most vulnerable patient/staff groups; set recovery objectives as soon as reasonably practicable; confirm the end of the acute (response) phase of the incident with CNE on-call manager/director and issuing a Major Incident STAND DOWN message to Trust staff; handover to normal operational management; instigate a hot-debrief process; review and, if necessary, request the update of CPFT, other emergency plans and business continuity plans. 5.2 Incident Controller(s) (CPFT Silver(s)) see action card at end of this plan During a critical incident or emergency the duties of the appointed senior manager(s) to manage the incident (OOH CPFT Silver(s)) may include during his/her shift, but are not limited to, the following: ensure his/her work mobile phone is switched on and functioning; co-ordinate the Trust response at the tactical level; obtain sufficient information to determine the current status of the response; conduct shared (i.e. with multi-agency partners), ongoing risk assessment ongoing risk assessment and management in response to the dynamic nature of the incident; understand how continually changing hazards/risks may affect the Trust s response and work with health/lrf partners to address these issues; formulate a tactical plan which takes account of all available information, including any predetermined emergency and business continuity plans and anticipated risks; monitor and protect the health, safety, human rights, data protection and welfare of individuals from/representing the Trust during the response; ensure that any individuals under his/her (functional or geographical) area of authority are fully briefed and debriefed; review actions taken at the Bronze (operational) level; review tactics with relevant others including key personnel involved in command, control, co-ordination and communications; ensure actions to implement tactics are carried out, taking into account the impact on patients and staff, their local communities and the environment; record fully his/her decisions, actions, options and rationale in accordance with current information, policy and legislation; ensure that all tactical decisions made, and the rationale behind them, are documented in a decision log (if no CPFT Gold input), to ensure that a clear audit trail exists for all Trust, health multi-agency debriefs and future Trust, health/lrf learning; identify where circumstances warrant Gold (strategic) level of management and engage the CPFT Gold as required (e.g. informing CPFT Gold when additional resources are required); determine priorities for allocating available resources; anticipate likely future needs, taking into account the possible escalation of emergencies; ensure resilient communications are in place at all tier of command (Gold (strategic), Silver (tactical), Bronze (operational)); ensure that any individuals under his/her (functional or geographical) area(s) of authority are fully briefed and debriefed; work in co-operation and communicate effectively with other responders; 9 October 2017 (Version 5.11) Page 15 of 113 Our Ref: CO/POL/002/073

16 provide accurate and timely information to warn and inform the Trust s patients/staff, contractors and local communities, working with CPFT Gold and comms lead (utilising social media appropriately) through a multi-agency approach; obtain and provide technical and professional advice from suitable sources to inform decision-making where required; liaise with relevant organisations to address the longer-term priorities of restoring essential services, and help to facilitate the recovery of affected communities; co-ordinate situation reporting with CNE and health/lrf partners; manage all incident record-keeping; attend or send an appropriate deputy to any Tactical Co-ordinating Group (TCG) if required; if required, establish and maintain an effective incident co-ordination centre in a safe location in relation to the incident; manage demands on resources; advise CPFT Gold and partner agencies on tactical health-related issues if required; communicate regularly and systematically with CPFT Gold; provide a tactical plan for recovery objectives; redeploy CPFT staff where safe and appropriate; evaluate the effectiveness of tactics and use this information to inform future practice. facilitate or make available debriefing facilities (supporting Bronze(s) and debriefing them). 5.3 CPFT Bronze commanders (Community Services and Mental Health North & South) see action card at end of this plan During a critical incident or emergency the duties of the appointed operational manager(s) may include, but are not limited to, the following: ensure his/her work phone is switched on and functioning; co-ordinate the Trust response at the operational level; conduct shared (i.e. with multi-agency partners), ongoing risk assessment and management in response to the dynamic nature of the incident; determine whether the event requires CPFT Silver involvement and make appropriate recommendations; make an initial assessment of the situation and reporting this to other responders in accordance with established procedures; ensure that any individuals under his/her (functional or geographical) area(s) of authority are fully briefed and debriefed; carry out a briefing at the earliest opportunity and update at regular intervals; update CPFT Silver on any changes, including any variation in agreed Trust, health/lrf tactics within their geographical/functional area of responsibility; if applicable maintain shared situational awareness through effective communications with health and LRF partners on scene, to assist in the implementation of any health or multiagency operational planning; identify and agree the triggers, signals and arrangements for the emergency evacuation of a Trust facility or area within it, or similar urgent control measures; conduct, record and share ongoing dynamic risk assessments, putting in place appropriate control measures with appropriate actions and review; prepare and implement an initial plan of action; understand how continually changing hazards/risks may affect the Trust s response and work with health/lrf partners to address these issues; 9 October 2017 (Version 5.11) Page 16 of 113 Our Ref: CO/POL/002/073

17 monitor and protect the health, safety and welfare of patients, staff (and other third parties on Trust estate) during the response, particularly those at scene or in affected areas; ensure actions are carried out, taking into account the impact on patients and staff, their local communities and the environment; record fully his/her decisions, actions, options and rationale in accordance with current information, policy and legislation; make and share decisions within your agreed level of responsibility, being cognisant of consequence management 5 - disseminate these decisions for action to relevant Trust colleagues and/or health/lrf partners; provide information requested by CPFT Silver(s)); identify which circumstances warrant silver (tactical) level of management and engage CPFT Silver as required (e.g. informing CPFT Silver when additional resources are required); maintain the Trust s critical clinical functions; implement the silver (tactical) plan, where applicable, within a geographical area or functional area of responsibility; work in co-operation and communicate effectively with other responders; confirm the availability and location of relevant services and facilities; identify any resource required and deploying them to meet the demands of the response; communicate any resource constraints to the relevant person, or finding suitable alternatives; obtain and provide technical and professional advice from suitable sources to inform decision-making where required; deal with individuals in a manner which is supportive and sensitive to their needs; attending a multi-agency Operational Co-ordinating Group if required; identify the challenges the Trust s operational planning may cause other health and LRF partners; consider Trust post-incident procedures and contribute to any incident hot debrief. 5.4 Trust staff asked to respond to a critical incident or emergency should: be familiar with this plan and the action card appropriate for their role; if required, respond in person and attend a designated incident co-ordination centre within 1 hour of callout; carry their Trust mobile phone and keep it switched on during their shift; carry valid NHS photographic identification; bring a (head)torch (spare batteries or smaller LED headtorch), Trust mobile phone charger, high-visibility vest, waterproof coat and warm clothing ideally keep these items in a grab bag in their car boot confidential information, work laptops/tablets or other valuable equipment MUST not be stored in any vehicles; keep any personal medication, dietary requirements and house/car keys close at hand in case of any unrelated emergency evacuation (e.g. fire in adjoining building); maintain a personal log: contemporaneous notes of any information given/received and any actions or decisions taken, options considered and rationale for the duration of their involvement in the incident using an appropriate format; irrespective of seniority under business-as-usual, perform any reasonable duty during incident response and recovery. 5 See APPENDIX I. 9 October 2017 (Version 5.11) Page 17 of 113 Our Ref: CO/POL/002/073

18 5.5 Incident response team(s) Once an incident has been declared by CNE (or partner agency), CPFT Gold will decide whether to assemble an incident response team. Roles in the incident response team might be performed initially by on-call managers, but when staff with local knowledge or skills deemed more appropriate for the requirements of the event/situation are available, CPFT Gold may allocate such roles as appropriate. The exact composition of the team will depend upon the nature and scale of the incident. Whilst not a definitive or exhaustive list, the responsibilities of the incident response team during a critical incident or emergency may include (but are not limited to): defining the nature of the incident in terms of the Trust s responsibilities; defining vulnerable groups of patients and staff within the affected geographical area(s); directing any member of Trust staff (irrespective of seniority) to perform any reasonable duty made necessary by the incident; possessing the authority to use any Trust assets for incident response and recovery; monitoring and, if necessary, managing business continuity (unless strategic-level business continuity management group (BCMG) and/or tactical-level central incident support group have been convened); if applicable, considering notification of other health/lrf partners; facilitating CPFT Bronze/Silver/Gold (GSB) command structure; establishing a helpline (or working collaboratively with NHS 111) to facilitate enquiries from Trust staff, other stakeholders and the public; implementing a system for logging calls to the helpline; providing approved media statements and facilitating interviews in support of coordinated multi-agency media activity to warn and inform the public; monitoring the welfare of staff and any contractors involved at all tiers of command who are responding to the incident, including health protection and psychosocial care; assisting Acute Trusts in appropriate early-supported discharge of patients to the community; determining the health needs and potential long-term follow-up of the affected patient population; assisting CPFT Gold to produce a detailed report as part of the debriefing. 5.6 Communications lead see action card at end of this plan If the Head of Engagement and Communications or a senior member of the communications team is unavailable, then CPFT Gold will appoint a senior manager who has received appropriate media training. Advice and guidance can be requested from CNE communications team (and LRF media cell if convened). Duties may include (during and after a critical incident or emergency but are not limited to): with an Executive Director s approval, initiating an effective cascade of information across the Trust in an appropriate, accurate, consistent and timely manner; communicate key messages effectively to staff and Trust stakeholders before, during and after an incident; recording and responding to media enquiries in a timely manner; providing updates on the incident to partner agencies and other stakeholders; preparing media statements for approval of CPFT Gold or another Executive Director; providing support to employees and managers who have been contacted by the media; ensuring business continuity arrangements are in place for their functional area(s) of responsibility. 9 October 2017 (Version 5.11) Page 18 of 113 Our Ref: CO/POL/002/073

19 6.0 ALERTING 6.1 This section sets out the mechanisms for alerting the Trust of a critical incident or emergency; internal levels of incident escalation, and the procedure for activating this plan. 6.2 To constitute an emergency an event or situation MUST require the implementation of special arrangements by one or more Category 1 responders. 6.3 Triggers This plan can be triggered in several ways to respond a potential or actual critical incident or emergency following: internal pressure within the Trust (i.e. an internal decision in response to a local event or situation); an external alert that multi-agency Silver (Tactical Co-ordinating Group) is being formed; an external alert that a multi-agency Gold (Strategic Co-ordinating Group) is being formed; an external alert that a partner agency has issued a Major incident STANDBY ; an external alert that a Major incident has been DECLARED NHS England direction (CNE, regional or national levels). 6.4 Internal alerts SEE APPENDIX B, PAGE During normal working hours Internal critical incidents and emergencies will be escalated through the Trust s line management structures and declared by either: the Chief Executive, Director of Nursing and Quality or the Director of Service Improvement. CPFT Gold (or one of the Executive Directors) will decide whether to notify CNE on-call manager (1st on-call) Out of hours Internal critical incidents and emergencies will be escalated through the Trust s on-call system. CPFT Gold will decide on appropriate action and whether to notify CNE on-call manager (1st on-call) Critical incidents/emergencies involving Trust services within Acute Trust Premises If an incident occurs on an Acute Trust site (Furness General Hospital, Westmorland General Hospital (WGH), Cumberland Infirmary Carlisle (CIC), West Cumberland Hospitals (WGH)) which affects, or has the potential to affect, any of the Trust s services on-site, the Trust s senior member on duty will alert their line manager during normal business hours, or, if out of hours, contact the Trust s switchboard to alert the relevant CPFT Bronze and then contact his/her line manager if available. Depending on the situation, CPFT Bronze will assess the situation and escalate, if necessary, to CPFT Silver, making recommendations for any immediate action. Identify in early course a direct copper wire analogue phone in case of subsequent local mobile phone or switchboard failure All incidents MUST be reported and subsequently investigated in accordance with the Trust s Incident and Serious Incidents that Require Investigation (SIRI) Policy. 9 October 2017 (Version 5.11) Page 19 of 113 Our Ref: CO/POL/002/073

20 6.5 External alerts External alerts will usually come via the North West Ambulance Service (NWAS) in accordance with an alerting protocol agreed with CNE For incidents requiring a co-ordinated health and social care response, or which may impact on NHS services, the wider community or the local population within Cumbria area, NWAS Regional Health Desk should notify CNE on-call manager (1st on-call) CALLS RELATING TO ALL EXTERNAL INCIDENT ALERTS SHOULD BE CONNECTED IMMEDIATELY VIA SWITCHBOARD TO CPFT GOLD CPFT Gold will contact CNE on-call manager (1st on-call), or a partner agency representative, to authenticate the call and gather further information. All alert messages in respect of a critical incident or emergency are required to adopt the METHANE alert format (APPENDIX D) Examples of such events include: unusual incidents (see below); emergencies/major incidents (standby or declared); explosions; multiple/mass casualty incidents; potential incident that could result in multiple/mass casualties; evacuations involving a number of people or where additional medical support may be required; large fires in residential areas which may require evacuation or result in increased demands on health services; fires in residential areas where asbestos is suspected or confirmed; flooding with potential for evacuation; flooding causing significant transport disruption; burning of non-natural wastes at agricultural premises with potential exposure to large numbers of people; toxic chemical release with the potential of affecting the population; surge escalation (outwith normal surge arrangements through Morecambe Bay and/or North Cumbria CCGs see Section 6.5.6) Morecambe Bay and/or North Cumbria CCGs should be alerted by NWAS of any routine operational or surge/escalation- related issues which may impact on NHS services or wider communities. Examples of such surge/escalation events include: operational emergencies/incidents affecting one or more provider organisations; business continuity issues affecting one or more provider organisations (e.g. loss of telephony); surge capacity issues including bed pressures, significant A&E activity, escalation or ambulance handover delays; significant pressure or activity affecting the ability of primary care out of hours organisations to sustain services. 9 October 2017 (Version 5.11) Page 20 of 113 Our Ref: CO/POL/002/073

21 6.5.7Morecambe Bay and/or North Cumbria CCGs commissioner-on-call is (are) responsible for escalating issues to NHS England when there is significant, sustained pressure experienced across Cumbria which potentially may impact on patient safety Unusual incident Notification of an unusual incident may also be received by CNE or another partner agency, for example, a localised weather event. CNE on-call manager (1st on-call) will assess the situation and decide upon an appropriate response. NOTE: an unusual incident for one partner agency may be actually considered a major incident by another responder (and vice-versa) Declaration of a major incident (emergency) Irrespective of the type of major incident, formal declaration (by partner(s)) is important as it: serves as the point when this plan can be activated by an Executive Director if deemed appropriate; allows a controlled, co-ordinated, and cohesive multi-agency response; (if applicable) allows community pharmacies to dispense out of hours Phases of a major incident (emergency) Most major incidents can be considered as having 4 stages: the initial response the initial action undertaken by the emergency services and may occur very rapidly; the consolidation phase - ongoing NHS action to support the local health economy; the recovery phase occurs when life-saving is complete and caring for those involved or affected by the incident can begin; the restoration of normality steps to return to business as usual and will involve investigation of the causes or circumstances of the incident, cost evaluation and examining risk reduction; and identifying issues and lessons for future incident management. 7.0 PLAN ACTIVATION 7.1 An Executive Director (CPFT Gold) MUST always make a formally recorded decision whether to implement (or not) CPFT. 7.2 In the first instance the nominated Executive Director (CPFT Gold) MUST consider declaring a critical incident before escalating to a major incident. A critical incident is when Trust facilities and/or resources, or those of neighbours, are overwhelmed. Early declaration of a critical incident or a major incident should be encouraged as it is easier to scale back the level of response as opposed to having to create crucial momentum during a complex, ongoing event/situation. 7.3 If this plan is to be activated, the Trust will employ the Gold-Silver-Bronze (GSB) system of command and control. CPFT Gold will usually instruct the Trust switchboard to contact key staff (minimum of CPFT Silver and communications lead) to indicate teleconference details or meeting location for convening an incident response team(s) before issuing the following message to all Trust staff: Major Incident DECLARED: Activate Trust. 9 October 2017 (Version 5.11) Page 21 of 113 Our Ref: CO/POL/002/073

22 7.4 Depending on the nature of the incident, CPFT Gold also has the option of bringing the Trust to a state of readiness by placing it on: Major Incident STANDBY. 7.5 If placed at Major Incident STANDBY, relevant staff should refer to CPFT Incident Response Plan (or other relevant emergency and business continuity plans as required) and locate relevant action cards. If the incident has been stood down by the alerting body, or this decision is taken by CPFT Gold, then the following instruction will countermand all previous incident-related messages: Major Incident CANCELLED. 7.6 The Trust s response may differ from that of other responder organisations. The nominated Executive Director MUST record the time and the rationale for when the decision was taken to activate CPFT. 7.7 Initial risk assessment a) It is critical to ensure a safe working environment (for patients), staff and others. First assess your environment and ensure it is safe for you. If it is not, you should move to a place of reasonable safety. You should then ensure that you or someone close to you has contacted the emergency services. Only then should you consider providing care if it is safe to do so. b) Dynamic: Ever changing and evolving. Hazard: Anything that can cause harm. Risk: Is there a chance that someone might be harmed by the hazard(s)? c) A careful, ongoing examination of the location for anything that could cause harm to patients/staff/others. d) Remember: People; equipment; materials; environment. 7.8 Safety Triggers for Emergency Personnel (STEP 123 Plus) for incidents which potentially may involve hazardous materials (HAZMAT)) The following guidance is used primarily by those responders who are likely to be first at scene or involved in such an incident, but have not received specialised training in HAZMAT incident management. STEP 1 STEP 2 STEP 3 SINGLE casualty (no discernible reason) TWO casualties (no discernible reason) THREE+ casualties (no discernible reason) Manage using normal protocols Approach and manage with caution. Consider ALL possibilities. Remember staff safety (do not become a victim). Provide an assessment of situation. Update CPFT Silver. Manage as an incident involving hazardous materials; risk-assess before intervening. Isolate casualties and seek specialist help immediately. Remember staff safety (do not become a victim) 9 October 2017 (Version 5.11) Page 22 of 113 Our Ref: CO/POL/002/073

23 7.8.2 STEP 123 Plus should not be used as a single indicator but in support of the overall risk assessment. 7.9 Non-activation of the If the decision is taken by an Executive Director not to activate this plan, the local (and, if applicable, regional and national) situation MUST be monitored and re-assessed constantly, preferably in consultation with CNE on-call manager and/or other affected responder(s). If any impacts can be dealt with using available resources, appropriate staff will be notified and a watching brief maintained. The situation should be reassessed as further information becomes available to determine if any additional action is required. The nominated Executive Director MUST record the time and the rationale for when the decision was taken not to activate the. 8.0 INCIDENT RESPONSE 8.1 Levels of commands Bronze (operational) refers to those providing immediate hands-on response to the incident, carrying out specific operational tasks either at the scene or at a supporting location (e.g. rest centre). Silver (tactical) are those who are in charge of managing the incident on the Trust s behalf. They are responsible for making tactical decisions, determining operational priorities, allocating staff and physical assets and developing a tactical plan to implement the agreed strategy. Gold (strategic) is responsible for determining the overall management, policy and strategy for the incident whilst protecting the Trust s interests. They should ensure appropriate resources are made available to enable and manage communications with the public and media. Additionally they will identify the longer-term implications and determine plans for the safe and efficient restoration to normal levels of service once the incident is brought under control or is deemed to be over. 8.2 The nominated Executive Director (CPFT Gold) protects life, property, the environment and the Trust s other interests, including preventing harm to its reputation, whereas CPFT Silver(s)) has (have) responsibility for managing all aspects of the Trust s response to and recovery from an incident. 8.3 Acting on instructions of CPFT Gold, CPFT Silver(s) and/or incident response team(s) will deploy available resources to achieve the Trust s strategic objectives. To ensure that command and control measures are instigated early in the response, the role of Bronze (operational) commander may be undertaken by the first senior manager on scene, preferably using the CPFT Bronze Commander action card at APPENDIX L. 8.4 For prolonged incidents, or those exhibiting potential for having significant medium- or long-term consequences, CPFT Gold and Chief Executive will review resource allocation in consultation with other Executive Directors. 8.5 The incident response team will consist, as a minimum, of: Incident Director (CPFT Gold); 9 October 2017 (Version 5.11) Page 23 of 113 Our Ref: CO/POL/002/073

24 Associate Director of Operations or senior manager (OOH CPFT Silver); Head of Engagement and Communications/senior member of the communications team ( communications lead ). 8.6 The primary functions of the incident response team(s) include collating information on the effectiveness of the operational/tactical response across the Trust, gathering intelligence from wider sources relating to the incident and ensuring the efficient flow of information through the chain of command and to partner agencies. The incident response team(s) may convene in person (at a designated incident co-ordination centre or stated rendezvous point (RVP)) or via teleconference or via other communications means, or a combination of these methods. APPENDIX B indicates how members of the incident response team(s) are alerted to an internal critical incident or emergency and APPENDIX C shows notification of a declared external critical incident or emergency. 8.7 Depending on the scale and scope of the incident, care groups may be requested to establish incident response teams. 8.8 INCIDENT CO-ORDINATION CENTRES Should the incident response team(s) wish to convene, two incident co-ordination centres are available at either Penrith hospital or Carleton Clinic. These do not have to be used as the incident response team(s) may deem another location more appropriate depending on the nature of the incident and its location. Both are split into command and control rooms and have resilient power and communications to ensure continued operation in the event of a power failure. Any alternative location used instead of the designated incident co-ordination centres should be risk-assessed and have appropriate facilities to enable effective and resilient communications. 8.9 INCIDENT MANAGEMENT BY COMMUNITY SERVICES 8.9.1This section outlines the support that CPFT community services might be expected to provide the Cumbria health economy and/or other LRF partners during a critical incident or emergency. Any such support MUST be agreed with the CPFT Gold District/community nurses Depending on the incident, various community nursing or specialist nursing teams may be required to provide support and could be deployed to assist various clinical functions, including but not limited to: assessing health needs at local authority rest centres; assisting at community hospitals (or minor injuries units within them) with accepting appropriate patients from acute care; deployment as part of teams to facilities providing medical services Alerting district/community nurses Community Managers (District Nursing Sisters or team leads) will be briefed and tasked with alerting appropriate nursing teams, or placing them on standby for possible deployment. 6 Subject to agreement between the Trust and other health organisations on clinical and corporate governance. 9 October 2017 (Version 5.11) Page 24 of 113 Our Ref: CO/POL/002/073

25 8.9.4 Deploying district/community nurses Shared (i.e. with multi-agency partners), ongoing risk assessment and risk management are essential before tasking any CPFT teams to operate outside their normal working environment to ensure staff safety and welfare and compliance with Nursing and Midwifery Council (NMC) guidelines, hence the following may need to be considered: review of health & safety, welfare issues and incorporate into a pre-deployment briefing, including lone working arrangements; tactical advantages of using GPs and practice nurses through Morecambe Bay and/or North Cumbria CCGs and/or CNE and keeping district/community nurses in reserve; assessment of which services/teams are/would be directly affected by the incident to ensure that the Trust s critical clinical functions performed by those services/teams are maintained (e.g. administration of insulin to diabetic patients in affected areas); confirmation of command & control arrangements for all staff to be deployed, including names/contact details of CPFT Bronze(s) and clarification of the appropriate route for escalating issues; confirmation of communications methods for all staff to be deployed Trust mobile numbers, any resilience issues with communications and preferably a default communications method (e.g. analogue landline numbers) Alerting community hospitals and minor injuries units Associate Directors of Operations or Senior Network Managers (OHH CPFT Silver) will alert community hospitals that might be required to accept appropriate in-patient transfers to create extra capacity at Acute Trusts sites and/or CPFT minor injuries units to receive minor casualties directly from the scene COMMAND, CONTROL, COMMUNICATIONS AND CO-ORDINATION (4C) CPFT Incident Director (CPFT Gold) Initially this role will be undertaken by CPFT Gold, but, as the incident progresses, the role might be rotated to another Executive Director. CPFT Gold provides leadership in an emergency response at the Gold (strategic) level and protects the Trust s interests, whereas CPFT Silver(s) manages incident response and recovery. Any rotation of CPFT Gold MUST include a formal handover (see APPENDIX F) CPFT Incident Controller(s) (CPFT Silver(s)) Senior manager(s) (OOH CPFT Silver) who at the request of CPFT Gold manages the Trust s response, or co-ordinates the tactical response for their (functional or geographical) area of responsibility. Depending on the incident, there can be more than one CPFT Silver (e.g. Associate Directors of Operations providing a tactical response within their respective care groups). Intentionally left blank 9 October 2017 (Version 5.11) Page 25 of 113 Our Ref: CO/POL/002/073

26 Multi-agency command & control structure (acute/response phase) GOLD Strategic Co-ordinating Group (SCG) Multi-agency media cell Recovery Co-ordinating Group (RCG) Science and Technical Advice Cell (STAC) SILVER Multi-agency Tactical Co-ordinating Group (TCG) BRONZE Multi-agency Operational Co-ordinating Group (OCG) NOTE: Structures depicted using dotted lines in the above diagram are not necessarily applicable to every incident Strategic Co-ordinating Group (SCG) SCG (Multi-agency Gold) will be convened and possibly chaired by the police Gold (strategic) commander. However, usually the first order of business for SCG is to elect a suitable chair. SCG looks at the wider impact of a critical incident/emergency and makes any high-level strategic decisions. CNE on-call Director or nominated deputy, will attend SCG and assume the role of health strategic commander (NHS Gold). Depending on the nature of the incident, it is also possibly for health strategic commander to chair SCG (see definitions at Appendix I) Science and Technical Advice Cell (STAC) Provides a single point of scientific advice to the SCG on the scientific, technical, environmental and public health consequences of an incident. A STAC is usually chaired by senior representative of Public Health England (PHE) Recovery Co-ordinating Group (RCG) This is another strategic decision-making body (also subordinate to SCG in the acute (response) phase and then) responsible for the recovery phase once handed over from the police Tactical Co-ordinating Group (TCG) Every major incident requires formation of at least TCG (multi-agency Silver), albeit a teleconference in which a Trust tactical-level (Silver) representative might be required. It should be noted that the police, for instance, may have a number of tactical commanders appropriate for specific functions. TCG devises the tactical plan to use resources to achieve the strategy set by SCG Media cell Ensures consistent communications are delivered by all key agencies involved in the response to the emergency (i.e. formally structured and recorded meetings and that require prompt and well-prepared attendances). Usually led by Cumbria Police communications lead during the acute (response) phase and the relevant local authority communications lead in the recovery phase. (Dotted lines in the diagram at above indicate where it is not necessarily applicable to every incident). 9 October 2017 (Version 5.11) Page 26 of 113 Our Ref: CO/POL/002/073

27 Tactical health cell (Not illustrated in the diagram at above). CNE may convene a tactical health cell to facilitate direct contact with local health and social care providers to monitor their current status and provide relevant advice and information to CNE representative(s) at SCG/TCG and/or LRF partners Operational Co-ordinating Group (OCG) OCG is a fairly recent addition to the multi-agency environment and was used during the 2009 Cumbria floods to provide operational (Bronze) command of the hands-on assets deployed at scene COMMUNICATIONS DURING A CRITICAL INCIDENT OR EMERGENCY ALL external communications MUST be channelled through the Trust s communications team in accordance with the Trust s Media Relations Protocol. The nature, timing and method of communications will be agreed with CPFT Gold. All media briefings/releases MUST be signed-off by an Executive Director During normal working hours ALL media enquiries MUST be directed to the communications team via the communications helpdesk: Telephone: communications.helpdesk@cumbria.nhs.uk 8.12 MAJOR IT/TELECOMMUNICATIONS/POWER DISRUPTION Depending on the nature of the incident, the following should be considered: (Trust) mobile phones; alternative internet protocol (IP) phones; depending on situation, tele or videoconferencing; analogue phones (on-call managers/directors should have access to analogue phone lines and handsets in case of power outages); authorised remote connection to Trust /or nhs.net accounts; safehaven fax machines at sites (observing Information Governance protocols); requesting assistance from multi-agency partners with Airwave; UHF handheld radios (CPFT (Bronze) managers for site specific incidents; sending messengers consider lone working implications; satellite phones; Private Mobile Radio (PMR) located in community hospitals (NOT FOR PATIENT- IDENTIFIABLE INFORMATION OR OTHER SENSITIVE INFORMATION). 9.0 ESCALATION AND DE-ESCALATION 9.1 Escalation or de-escalation of the incident does not necessarily occur sequentially. It can be driven by the nature and scale of the incident and the appropriateness of response. 9 October 2017 (Version 5.11) Page 27 of 113 Our Ref: CO/POL/002/073

28 Criteria for Escalation Increase in geographic area or population affected (pandemic, flooding etc). The need for additional internal resources. Increased severity of the incident. Increased demands from government departments, from Trust services or from partner agencies or other responders. Heightened public or media interest Criteria for De-escalation Decrease in geographic area or population affected. Reduction in internal resource requirements. Reduced severity of the incident. Reduced demands from partner agencies or government departments. Reduced public or media interest SAFETY & WELFARE 10.1 There is no expectation that you should put your own safety at risk. For example, Nursing & Midwifery Council s (NMC) code states that nurses (and midwives) must take account of their own safety, the safety of others and the availability of other care options (e.g. paramedics). You may be able to help or assist in this type of situation but you should always follow the advice of the emergency services at the scene of an incident or emergency and find a place of reasonable safety if told to do so When delivering any type of care it is important that you only act within the limits of your knowledge and competence. It is acknowledged that not all healthcare professionals are qualified first aiders but they may be able to support other members of the emergency services or those injured or distressed in other ways The responsibility for identifying the need for welfare support rests collectively with the individual member of staff, their line manager and Human Resources (HR). There is an obligation on each member of staff to provide support in terms of colleagues welfare and bring to the attention of a line manager or CPFT Silver or another senior manager any matter which might do harm to themselves or a colleague CPFT Gold and CPFT Silver(s) will need to take account of the following in terms of health, safety and welfare: any known/stated restriction on work concerning a member of staff on health grounds (e.g. not having an appropriate vaccination prior to a mass infectious outbreak); any training or professional qualification that would be a prerequisite to undertaking specific response duties safely; any other circumstances that might make working unsafe (e.g. severe staff shortage); any official communications from bodies with emergency powers by law; the need for personal protective equipment; dietary requirements of staff and third parties Lone working When deploying to a designated location, it is probable that staff will travel independently. All staff MUST comply with the Trust s Policy for Lone Working Personal protective equipment All staff attending the scene(s) of an incident(s) MUST be appropriately dressed (i.e. for protection and identification purposes) including high visibility jackets and other appropriate personal protective equipment Safety cordons Cordons are established to control both the movement of vehicles/personnel in and out of the scene, thus providing immediate security of the hazard area(s) and potential crime scene(s). 9 October 2017 (Version 5.11) Page 28 of 113 Our Ref: CO/POL/002/073

29 Access to the inner cordon will be strictly limited to requested clinical staff with valid photographic NHS ID, a specifically designated task, pre-hospital care skills and training and wearing appropriate PPE. A NWAS manager will monitor the health, safety and welfare of all NHS staff at scene Rendezvous point (RVP) Normally established in the outer cordon and controlled by a police officer in an appropriate reflective tabard Slips, trips and falls Whilst potentially far removed from any incident scene, all Trust facilities should be vigilant of slips, trips and falls, including in the incident co-ordination centres(s), for example, increased use of extension cables to power portable equipment or other cabling to support IT resilience SUSTAINABILITY AND HANDOVER 11.1 Early consideration of whether the incident is likely to require an extended commitment by Trust and/or possible geographical relocation of tactical and operational commands, other assets, and any logistical support required Particular care should be taken during prolonged responses as tiredness and fatigue makes staff more susceptible to errors/accidents. With possible disruption to blue-light services, enhanced vigilance in terms of fire safety and first aid cover is essential at all levels of CPFT command. Due regard should be given to the European Working Time Directive, so arrangements should be made to implement shift patterns to provide relief staff to take over key roles within each tier of command (Gold, Silver, Bronze) Shift patterns should ideally coincide with other partner agencies changeovers. The relief CPFT Gold and relief CPFT Silver(s) should arrive at least 30 minutes before their nominated start time for handover. Other relief staff should report to their designated locations, sign-in and be ready for a formal handover of duties at least 10 minutes before their shift starts MANAGEMENT OF STAFF DURING A CRITICAL INCIDENT OR EMERGENCY 12.1 All CPFT staff (including seconded, bank, agency) will be required to work flexibly in terms of roles and workplace arrangements during a critical incident or emergency. Changes to staff working arrangements should be documented and details forwarded to HR as soon as reasonably practicable. Staff are not obliged or compelled to vary their contracts of employment Changing working hours CPFT Gold or CPFT Silver(s) can temporarily create extra workforce capacity to bolster incident response and/or recovery and to maintain the Trust s critical clinical and management functions by inviting staff to change their working conditions by: requesting part-time staff to increase their working hours as a temporary measure; seeking permission from staff who work flexibly to alter their arrangements temporarily; suspending and cancelling pre-booked leave; 9 October 2017 (Version 5.11) Page 29 of 113 Our Ref: CO/POL/002/073

30 asking HR to contact recent retirees to assist the response; 7 asking trained bank staff to assist the response Staff maintaining contact with line manager Staff working away from their normal workplace should notify their line manager when they: report for duty; are asked to work somewhere else; go off-duty Redeployment Staff might be requested to work from other locations which could include working: at a local authority rest centres with evacuees or survivors; (depending on skills, knowledge and experience) at a different department; at another Trust facility or site (e.g. incident has denied access to the normal place of work); at another health organisation, or site managed by another Trust Cancelling or suspending scheduled meetings and training If an external or internal incident occurs during normal business hours, CPFT Gold or CPFT Silver(s) can request cancellation or suspension of internal training by contacting Learning Network. If Trust staff are attending external meetings and training (e.g. out of county), CPFT Gold or CPFT Silver(s) can request that those staff return to base as soon as safe and practicable and advise other staff not to attend training until message: Major Incident STAND DOWN has been issued SECURITY 13.1 Managers MUST maintain strict control of entry/exit points to incident co-ordination centre(s) and affected facilities. Minimising those present to essential staff only in the control room(s) will also reduce the levels of distraction and noise. The command room will be restricted to CPFT Gold, any other Executive Director, the communications lead, a loggist and specific staff/third parties providing strategic advice. Increased staff vigilance across the whole Trust is required to monitor any unusual or suspicious movements of persons during an incident. If in doubt, dial 999 (or use agreed local number if on an acute site) and ask for the police MAINTAINING BUSINESS CONTINUITY 14.1 Each directorate/care group/department/service/team is responsible for completing a business impact analysis (BIA) which identifies the dependencies (including those of suppliers, partner organisations and other relevant interested parties) required to deliver its prioritised activities; assesses the impact of disruption(s) on its critical clinical and management functions; and identifies resources required to resume normal service. Each directorate/care group/department/service/team will categorise its activities according to their priority for recovery. Business continuity plans will be based on risk assessment(s) to ensure 7 All staff who have retired more than six months ago will be health-screened, DBS checked and a reference sought from their previous line manager. Subject to appropriate checks, nurses whose professional registration has lapsed could be engaged as healthcare assistants. 8 Subject to agreement between the Trust and other health organisation(s) on clinical and corporate governance. 9 October 2017 (Version 5.11) Page 30 of 113 Our Ref: CO/POL/002/073

31 the proposed business continuity response and recovery actions are safe and proportionate in relation to level of perceived disruption ONLY Directors, Associate Directors (of Operations), Deputy Directors, (other) Heads of Service, Senior Network Managers may invoke relevant business continuity plans to protect the Trust s critical clinical and management functions as far as is reasonably practicable under the circumstances. Until authorisation is given for activating business continuity plans, local disruption will be managed as service continuity issues by local line management. Incident response team(s) and/or (tactical-level) central incident support team (CIST) might be convened to review local business continuity arrangements and recovery objectives INFORMATION TECHNOLOGY (IT) RESILIENCE 15.1 Certain IT functions will be critical to the Trust s incident response and recovery as well as BCM. IT managers MUST keep the CPFT Incident Controller(s) (Silver(s)) and the Trust s Head of Information fully informed of relevant business continuity/disaster recovery activities. All non-essential scheduled work should be suspended following a risk assessment(s). Appropriately trained IT staff should be redeployed to support critical telecommunications and IT infrastructure VULNERABLE PATIENTS AND STAFF 16.1 The Trust will endeavour to provide the secure exchange of appropriate data, where available and reasonably practicable, on patients and staff deemed as possibly requiring extra support during the incident, or those patients accessing Trust services or staff residing within an affected geographical area(s) CPFT Silver(s) are responsible for managing the collection and release of relevant information on vulnerable persons (where appropriate) to partner agencies, preferably to those with information sharing agreements in place with the Trust The following examples are not definitive or exhaustive, but are those assessed by Cabinet Office as having increased vulnerability during critical incidents and emergencies. This provides only broad guidance as people s vulnerability will depend entirely on the type of incident and support available. those already ill, either acutely or with chronic health problems; patients dependent on medication for disease management, symptom support or pain relief (e.g. end-of-life, palliative, chronic obstructive pulmonary disease (COPD), home oxygen); people with mental health problems; people with learning disabilities; parents with babies, young children; pregnant women; the elderly and confused; individuals whose first language is not English who may experience difficulty in accessing services. 9 October 2017 (Version 5.11) Page 31 of 113 Our Ref: CO/POL/002/073

32 16.4 Interpreting services Staff should adhere to the Trust s Interpreter Policy, which sets out access to services for those whose first language is not English, or those who are deaf, or deafblind, or hard of hearing Language line Language Line provides telephone interpreting services. No special equipment is required and the service can be accessed from any telephone. Language Line requires the following information: the identification number; security quote; the name of the person requesting the interpreter; confirm that that it is for Cumbria Partnership NHS Foundation Trust ; the language required; if appropriate, state if a male or female interpreter is require or any other special requests CRITICAL INCIDENTS OR EMERGENCIES INVOLVING CHILDREN AND YOUNG PEOPLE 17.1 This section provides consideration of some of the physical, emotional and technical challenges for healthcare staff who do not deal routinely with children and young people The majority of incidents involve children either directly or indirectly. Children can be more vulnerable than adults in emergencies for a number of reasons. In younger children size, skeletal maturity and other physiological characteristics make them more susceptible to serious injury. Considerations may include physical and psychological trauma; bereavement; parents/carers are possibly incapacitated and unable to care for their child/children; other reasons for separation from parents/carers during or after an incident; inadequate resources to cater for the specific requirements of children and young people, including those with a disability or special educational needs Irrespective of whether treating adult or paediatric patients the principle of achieving the most appropriate clinical outcome for the most casualties applies during emergencies Children should not be entrusted by staff to adults with no connection to the child (e.g. in a rest centre) When consultation with a person with parental responsibility or court is impossible, or the person with parental responsibility refuses consent, the courts have stated that doubt should be resolved in favour of the preservation of life. It will be acceptable to undertake treatment to preserve life or prevent serious damage to health in such cases Technical challenges of children under 5 years include (but not limited to): airway management; vascular access; pain management; titrating medication to body weight; and temperature control In pre-verbal groups and small children (as there tends to be regression in young children to behaving younger than they are), communication (i.e. the ability to describe or assert their needs to others) is also a significant challenge. Behavioral and developmental immaturity may also impair their ability to recognise or escape from hazardous environments. 9 October 2017 (Version 5.11) Page 32 of 113 Our Ref: CO/POL/002/073

33 17.8 Family units are particularly strong during emergencies. There will be a strong imperative for victims to search for, or to reunite with, loved ones from whom they have become separated. Where safe and appropriate, family units should be kept together for as long as possible and care should be taken to reassure victims that they will be reunited with family members/carers/significant others as soon as practicable Provision for parents and carers should include: a clearly-signed reception area; safe, appropriate, comfortable surroundings; reasonably near to patients and shielded from any intrusive media attention; access to telephones; refreshments; toilets; facilities for washing; and access to psychological first aid The practical and psychosocial needs of children and young people and their families/carers should be considered when agreeing where they are to be treated particularly if other members of the family have been involved in the incident CULTURAL, RELIGIOUS AND DIVERSITY ISSUES 18.1 Health and safety is paramount during critical incidents and emergencies. Whilst diversity issues will not have primacy over preserving life or alleviating suffering, staff should remain sensitive to the requirements and aspirations of casualties, survivors and their families from different communities and social groups, both of those resident in the county, and possibly those travelling through or visiting tourist destinations in Cumbria Whilst the police (Family Liaison Officers) and local authorities would oversee this type of support, staff should be aware of the following, including but not limited to: access to interpreters or to the telephone interpreting service; cultural considerations in respect of medical treatment, including ensuring enough female clinical staff are available, personal hygiene and toilet needs, and use of needles for fluid therapy; dietary requirements and fasting; provision of separate areas for men and women, particularly at rest centres; arrangements for ensuring places are set aside for personal worship; sensitivity to various cultural attitudes and requirements in dealing with the dying, death, burial and bereavement; ensuring as far as reasonably practicable temporary facilities are suitable for disabled persons and assistance dogs MANAGEMENT OF PUBLIC HEALTH INCIDENTS 19.1 A public health incident may arise through: a single case of a serious illness with major public health implications (e.g. botulism where action is necessary to investigate and prevent ongoing exposure to the hazardous agent); two or more linked cases of unexplained illness that could indicate the possibility that they may both be caused by the same known or unknown agent or exposure (i.e. an outbreak); higher than expected number of apparently unlinked cases or geographic clustering of a serious pathogen; a high likelihood of the population being exposed to a hazard (e.g. a chemical or infectious agent at levels sufficient to cause illness), even though no cases have yet occurred. 9 October 2017 (Version 5.11) Page 33 of 113 Our Ref: CO/POL/002/073

34 20.0 MULTIPLE OR MASS CASUALTY INCIDENTS 20.1 With these types of incidents, there is a likelihood for a greater number of casualties, including fatalities and for incidents to occur simultaneously or at multiple sites. Whilst local authorities are responsible for establishing reception centres for evacuees or survivors, the Trust s community health services might be requested to provide assistance at these centres. Anyone requiring urgent medical treatment should be taken (or advised to attend) the nearest available accident & emergency (A&E) department. During a multiple or mass casualty incident, transporting casualties to a place of definitive care might be impractical. Provision of healthcare services during this type of scenario will be agreed between the CPFT Gold and (NHS England) health strategic commander (NHS Gold). Specially trained police officers might be deployed to receiving hospitals to document known casualties information. Close contact should be also maintained with NWAS. Category Patient condition % of total P1 Casualties needing immediate life-saving resuscitation and/or surgery 25% P2 Stabilised casualties needing early surgery but delay is acceptable 25% P3 Casualties requiring treatment but a longer delay is acceptable 50% Illustrative planning assumptions for preparing for mass casualties Source: Mass Casualty Incidents A Framework for Planning (DH 2007) 21.0 MANAGEMENT OF BURN-INJURED PATIENTS 21.1 Whilst every effort should be made to ensure that clinicians have appropriate skills to assess and stabilise burn-injured patients, but if a patient has other acute life-threatening injuries they will be transferred on to the appropriate service which is required by their clinical needs. However, the nature and scale of this type of event might require staff to seek specialist advice (via CPFT Silver) from NHS England PROVISION OF HEALTHCARE SERVICES AT REST CENTRES 22.1 NOTE: With any deployment to a rest centre, inclusion of (a) Nurse Practitioner (preferably a non-medical prescriber) with experience in unscheduled care, acute A&E and/or minor injuries; (b) Band 5 unscheduled care nurse should also be considered; and (c) a local clinical manager should accompany both nurses to act as CPFT Bronze at this location The Trust may be requested to deploy its community health staff to rest centres to (but not limited to): assess evacuees/survivors and provide advice on self-care; signpost evacuees/survivors to appropriate community health, mental health or social care colleagues; ensure continuity of care for those receiving treatment through community health services; provide information and reassurance about any health protection issues arising from the incident; arrange psychological first aid; facilitate replacement medication in conjunction with local GPs and equipment (e.g. prescription glasses and walking aids) for persons evacuated from their place of residence. 9 October 2017 (Version 5.11) Page 34 of 113 Our Ref: CO/POL/002/073

35 23.0 CROWD BEHAVIOUR 23.1 Some people may exhibit negative behavioural and emotional responses as well as those suffering from visible physical injuries. To assist in preventing unrest and to provide reassurance, the Trust should provide positive, effective leadership. Clear, credible and timely information from the Trust (before if practicable), during and after the incident will aid order and assist with an efficient response FIREARMS AND WEAPONS ATTACKS 24.1 Attacks involving firearms and weapons are still infrequent but it is important to be prepared to cope with such an incident. In the event of an attack take the following 4 actions under the blue headings: 24.2 Stay Safe Under immediate GUN FIRE Take cover initially, but leave the area as soon as possible if safe to do so Nearby GUN FIRE - Leave the area immediately, if possible and it is safe to do so. Leave your belongings behind. Do not congregate at evacuation points. COVER FROM GUN FIRE Substantial brickwork or concrete Engine blocks of motor vehicles Base of large live trees Earth banks/hills/mounds COVER FROM VIEW ONLY Internal partition walls Car doors Wooden fences Curtains 24.3 REMEMBER - out of sight does not necessarily mean out of danger, especially if you are not in cover from gun fire IF YOU CAN T ESCAPE - consider locking yourself and others in a room or cupboard. Barricade the door then stay away from it and any windows. If possible choose a room where escape or further movement is possible. Silence any sources of noise, such as mobile phones, bleeps, pagers, printers, fax machines that may give away your presence See The more information that you can pass to police the better but NEVER risk your own safety or that of others to gain it. Consider using CCTV and other remote methods where possible to reduce the risk. If it is safe to do so, think about the following: Is it a firearms/weapons incident? What is the exact location of the incident? What else are they carrying? Bags? Number and description of attackers? Moving in any particular direction? Type of firearms: long-barrelled or handgun(s)? Are they communicating with others? Number of casualties/people in the area Tell POLICE - contact them immediately by dialling 999 (or use agreed local number if on an acute site), giving them above information (under See ). Use all the channels of communication available to you to inform staff, visitors, neighbouring premises, etc. of the danger. 9 October 2017 (Version 5.11) Page 35 of 113 Our Ref: CO/POL/002/073

36 24.7 Act Secure your immediate environment and other vulnerable areas. Keep people out of public areas, such as corridors and foyers. Move away from doors/windows and remain quiet until told otherwise by the police or if you need to move for safety reasons, such as a building fire. Beware of the risks posed by apparent cries for help Armed police In the event of an attack involving firearms or weapons, a police officer s priority is to protect and save lives. Please remember: initially they may not be able to distinguish you from the attackers. officers may be armed and may point guns at you. they may have to treat you firmly. Follow their instructions; keep hands in the air/in view. avoid quick movement towards the officers and pointing, screaming or shouting HAZARDOUS MATERIALS (HAZMAT) OR CHEMICAL, BIOLOGICAL, RADIOLOGICAL, NUCLEAR AND EXPLOSIVES (CBRNE) INCIDENTS 25.1 Follow Section 7.8 above: Safety Triggers for Emergency Personnel (STEP 123) for incidents which potentially may involve hazardous materials (HAZMAT)) The local NHS response to a HAZMAT or CBRNE incident involving the Trust would be largely led by NWAS, which has trained personnel, specialist equipment, specific procedures for decontamination and the administration of countermeasures (antidotes) Early recognition of contamination and immediate control measures to contain any potentially contaminated casualties and affected areas are crucially important. Consideration will be given to directing potentially affected Trust buildings to lockdown (close and secure windows, lock doors at points of entry and exit, and switching-off all air conditioning, ventilation and other systems or other equipment that circulate air (e.g. fans, computers, printers, photocopiers, vacuum cleaners and heaters)). Operate a door-bell policy, where practicable, in order to safeguard patients, staff, visitors, contractors and maintain the delivery of essential services LOCKDOWN 26.1 All staff in buildings on lockdown should be briefed on access to keys in the event of another emergency (e.g. fire) and on amended patient flows following lockdown. All affected Trust facilities will be advised to display a sign (template at APPENDIX H) in a closed, (locked) external window or locked entrance glass door panel, so that it is clearly visible to anyone approaching the building that the facility is closed Appropriate patients (i.e those not detained under the Mental Health Act) or third parties cannot be detained against their will; they should be warned that they are leaving an area of relative safety and, if possible, the time and wording of this warning recorded and a signature from those wishing to leave that they have received a warning (that includes the possible dangers) and accept the associated risks. If they insist on leaving, they should exit via a solid wooden door (i.e. no viewing panel or surrounding glazing to indicate movement). Good observation should 9 October 2017 (Version 5.11) Page 36 of 113 Our Ref: CO/POL/002/073

37 be maintained of the immediate area beyond the exit point before the person is released. If practicable (i.e. if a message can be passed securely), notify the police that a person is about to exit the building. Release should be undertaken as quickly and quietly as possible and then secure the door immediately. Afterwards keep occupants away from the door (other doors and windows) CPFT Local Security Management Specialists (LSMSs) will advise CPFT Gold and Silver(s) on specific lockdown arrangements CATASTROPHIC INCIDENTS 27.1 An incident where existing resources are unable to meet the potentially large number of casualties. NHS England will assume full command and control, or there will be national coordination of the incident. Emphasis will be on mutual aid across the local health economy ADMINISTRATION 28.1 Legal implications Failure by the Trust to demonstrate that reasonable procedures were implemented and executed in the response to and the recovery from a incident or emergency could be a breach of either criminal or civil law. Senior staff managing incident response and recovery MUST fully understand that health and safety legislation MUST be observed to at all times and the Trust s risk management policies and procedures applied to safeguard the welfare of patients, staff, visitors, contractors and any other third parties Protective marking of information Pre-defined classifications usually OFFICIAL, or sometimes OFFICIAL SENSITIVE - can be assigned to information assets (e.g. paper, electronic, written, spoken, physical or other) through marking with a stamp or handwritten note on the top of a document, or verbal communication during a conversation Information sharing Appropriate expert advice should be sought on fair and lawful processing, including whether a Data Protection Act 1998 condition is met or whether a duty of confidentiality applies. During a critical incident or emergency, it is more likely than not that it will be in the interest of the individual data subjects for personal information to be shared to protect the person s vital interest or is necessary to perform a public function in the public interest. The sharing of personal data and sensitive personal data requires further consideration before sharing across agencies and the DECISION-MAKING MODEL (APPENDIX J) can be used to guide what to release and to whom. In particular, in considering the legal and policy implications, the following are relevant: a legal framework to share information is required in an emergency situation this will generally come from Common Law (save life/property), the Crime and Disorder Act 1998 or the Civil Contingencies Act 2004; formal information sharing agreements (ISAs) may exist between some or all responding agencies. there should be a specific purpose for sharing information; information shared needs to be proportionate to the purpose and no more than necessary; the need to inform the recipient if any of the information is potentially unreliable or inaccurate; 9 October 2017 (Version 5.11) Page 37 of 113 Our Ref: CO/POL/002/073

38 the need to ensure that the information is shared safely and securely it MUST comply with the Government Security Classifications (see bibliography) if appropriate; what information is shared, when, with whom and why, should be recorded Logging messages Anyone receiving a message during an incident should: record the date/time (24-hour format) the message was received; record the exact wording of the message; record the name and contact number of the person giving the message Briefings Important at all three tiers of command (Gold, Silver and Bronze) to keep staff informed of progress and current Trust strategic objectives; it is not a discussion forum. Participants should be pre-warned of the start time and the delivery kept tightly focussed on salient points using the SBAR format. Contents of briefings should be logged. Situation (description of incident, location) Background (likely impact, anticipated issues, details of current and likely Trust response, number of patients, staff, other casualties involved) Assessment (risk assessment, health & safety issues, urgency of Trust assistance: IMMEDIATE, within a few hours or standby situation) vulnerable persons, staff welfare issues) Recommendations/Actions: important contact information (inc. any analogue phone numbers), individuals/teams roles, other relevant information, opportunity to ask questions Situation reporting (BLANK TEMPLATE - APPENDIX E) The scale and scope of the incident will shape the nature and frequency of informationgathering. CNE will probably require situation(al) reports. Specific information requirements and the frequency of updates will be set during the early stages of an incident. These are known as the response rhythm (or battle rhythm or operating pace ) and allow for planned situation reporting at pre-determined times using the following: CPFT Gold to health strategic commander (NHS Gold) - SITREP or Common Recognised Information Picture (CRIP) CPFT Silver(s) to CPFT Gold - SITREP Template (APPENDIX E SITREP/EXCEPTION FORM) CPFT Bronze(s) to CPFT Silver(s) - SITREP Template (APPENDIX E SITREP/EXCEPTION FORM) 28.7 Trust staff asked to submit SITREPs MUST do so in a timely manner as deadlines are usually determined by Central Government and not at the discretion of the Trust Documentation Those staff undertaking specific roles as part of this plan are legally responsible for producing their own documentation (i.e. maintaining a personal log that details any information received/given, any decisions/actions taken, options considered and rationale for those decisions). The more time that passes between action and recording the action undermines the credibility of the entry. 9 DO NOT WAIT UNTIL THE END OF YOUR SHIFT TO COMPLETE YOUR PERSONAL LOG. 9 Meadows-Keefe, J, Getting it all on record. Continuity Q4. p.38 9 October 2017 (Version 5.11) Page 38 of 113 Our Ref: CO/POL/002/073

39 28.9 Use an appropriate logbook or, if unavailable, a hardback ruled notebook with bound leaves (e.g. A4 format bound diary). These records will form the definitive record of the response and may be required at a future date as part of an inquiry process. Such records will also enable the Trust to prove its damages (e.g. any physical injury or property damages) and/or identify issues and lessons that would improve future response and recovery activities Control room chronological log for use during critical incidents and emergencies only CPFT Silver MUST ensure this is maintained for the duration of the incident. This log MUST record dates and times (24-hour format) of all information received and given (i.e. all communications relating to the incident that involve CPFT Silver and/or a tactical-level incident response team(s). This should be completed in an appropriate logbook format. Once a control room has been established, administrative staff will be allocated to support the incident response team, including loggists to maintain this official incident log In addition to his/her personal log, CPFT Gold is also required to maintain a decision log which MUST be completed at the time any decision is taken (e.g. a CPFT Gold action) and preferably undertaken by a trained loggist. Equally if no CPFT Gold input, then CPFT Silver MUST maintain a decision log (i.e. an entry completed at the time each decision is taken) and preferably recorded by a trained loggist) as well as completing a personal log Loggists Incident log(s) MUST be regarded as the Trust s definitive legal record. Preferably trained loggists (i.e. those staff who have been trained to capture decisions during incidents should perform this task). Unless producing the (tactical) control room chronological log, loggists MUST only log for ONE decision-maker. Administrative staff given the role of loggist will accompany their nominated decision-maker and will be responsible for (but not limited to) documenting: specific information relating to the Trust at meetings, including decisions made by their nominated decision-maker, actions, options considered and rationale for those decisions; any Trust discussion or activity that occurs between meetings; cross-referencing any exhibits used in decision-making (e.g. use of the Joint Decision Model, maps, flipchart diagrams received or produced), using the following convention: EXHIBIT_full initials of originator/number in letters_number in brackets_description (e.g. EXHIBITABC/ONE(1) Annotated Ordnance Survey map sheet number 91) Documentary evidence Under no circumstances MUST any document in any way relating, however slightly, to the incident be destroyed, amended, or held back During an incident, procedures for the confidential destruction of documents and archiving MUST be suspended. This suspension will be lifted once procedures are in place to safeguard against the accidental destruction of any incident-related documentation. Documents generated at the time of an incident, however seemingly unrelated, may only be destroyed with the written permission of the Chief Executive Following an incident, the Trust might be requested to provide evidence to a competent authority, such as enforcement agencies (e.g. Cumbria Police and/or HSE), a judicial 9 October 2017 (Version 5.11) Page 39 of 113 Our Ref: CO/POL/002/073

40 inquiry, coroner s inquest or as part of civil court proceedings. All documentation should be signed, countersigned, dated (24-hour format) and then sealed in envelopes (sign and date across the closed seal of the envelope) and held securely until collected by the police or an authorised manager Any other evidence recorded on whatever medium (e.g. post-it note, flipchart paper) MUST be retained and held securely for evidential purposes. All electronic records should be copied directly to non-volatile media (i.e. paper). Depending on the nature of the incident, records MUST be kept for at least seven years or indefinitely Incident recordings (audio & video) Any recordings should be made in accordance with the Trust s Photography and Video Recording Policy and Procedures. The communications team has been trained and has access to video recording equipment. Use of dictaphones is subject to all parties agreeing prior to use Forensic evidence Every incident is a potential scene of crime, so staff should ensure the preservation of evidence as far as reasonably practicable. In a minor injuries unit, patients clothing, used dressings (from pre-hospital care), property and any foreign object debris (e.g. shrapnel fragments found on the patient s clothing) should be sealed in clear plastic bags and marked with the patient s name. If authorised to attend the scene of an incident all nitrile gloves and equipment (e.g. resuscitation bags) used should be left in-situ MUTUAL AID ARRANGEMENTS 29.1 Mutual aid arrangements between health providers in Cumbria exist in the form of a memorandum of understanding that gives Chief Executives the ability to request support from neighbouring NHS organisations during excessive demand for services STAND DOWN 30.1 ONLY a CPFT Executive Director can issue Major Incident STAND DOWN to the Trust. The health strategic commander (NHS Gold) will inform the CPFT Gold of Major Incident STAND DOWN for a declared external major incident, which CPFT Gold will relay directly to CPFT incident response team(s), or switchboard or communications team to cascade message: Major Incident STAND DOWN to Trust staff. CPFT Gold MUST record the time the message: Major Incident STAND DOWN was received and from whom. For internal major incidents, the decision to stand down will be taken by either the Chief Executive, Director of Nursing and Quality, or Director of Service Improvement. On receipt of this message all incident documentation MUST be secured and any equipment used should be appropriately cleaned, checked and returned to its correct storage location in readiness for another incident. Any consumables used should be replenished as soon as reasonably practicable DEBRIEFING/LESSONS IDENTIFIED 31.1 Hot debriefs A hot debrief will be conducted by either CPFT Silver(s) or the Resilience Manager with involved staff within 24 hours and as soon as reasonably practicable after stand down of a 9 October 2017 (Version 5.11) Page 40 of 113 Our Ref: CO/POL/002/073

41 critical incident or emergency. This also provides an opportunity to correct any recognised issues/errors in terms of emergency response/recovery. If required a full debrief will be held within 14 working days of the incident. The initial incident report will be produced within 28 working days Participants should be given every opportunity to contribute their observations freely and honestly. CPFT Silver(S) MUST ensure that the full debriefing process is followed An operational debrief should not be confused with discussing staff welfare issues, which should form part of the Trust s psychosocial care for such incidents Debriefs should not interfere with or comment on any investigation of the incident A post-incident report should reflect the actual events and actions taken throughout the response as well as indicating areas where improvements can be made in future, including but not limited to: a brief description of the incident; involvement of the Trust; involvement of other responding agencies; implications for the strategic management of the Trust; actions undertaken; vulnerabilities/future threats/forward look; chronology of events; organisational learning and main areas for progression; an action plan (including owner and completion date for each action) It is important to note that such debriefs and related documentation are disclosable to those involved in any legal proceedings Cold/multi-agency debriefs It is the responsibility of the Director of Nursing and Quality i.e. the Accountable Emergency Officer (if absent, CPFT Gold involved with the incident) to ensure that the Trust is adequately represented at any cold/multi-agency debriefing sessions following any critical incident or emergency SERIOUS UNTOWARD INCIDENTS 32.1 If an internal critical incident or emergency has affected the Trust s activities, led to damage of Trust property, or has significant implications (legal, reputational) for the Trust, then it will also need to be handled in accordance with the Trust s Incident and Serious Incidents that Require Investigation (SIRI) Policy PSYCHOSOCIAL SUPPORT 33.1 The nature of follow-up arrangements for both physical and psychosocial care of casualties or other patients or staff affected by an incident will depend on the severity of their condition. Patients and staff will be treated using whatever services are most appropriate for their needs. A stepped approach for offering psychosocial support to staff affected by an incident including access to psychological first aid through the Trust s occupational health provider. 9 October 2017 (Version 5.11) Page 41 of 113 Our Ref: CO/POL/002/073

42 34.0 RECOVERY 34.1 DEPENDING ON THE INCIDENT, THE RISK OF INJURY CAN BE GREATER IN THE RECOVERY PHASE THAN DURING THE ACTUAL RESPONSE The recovery phase should begin at the earliest opportunity following the onset of an incident, running in tandem with the response activities. It continues until the disruption has been rectified, demands on services have returned to normal levels, and the needs of those affected (directly and indirectly) have been met The incident response team(s) (and/or the strategic-level business continuity management group (BCMG) and/or tactical-level central incident support team (CIST) if convened)) will meet to assess the current and anticipated disruption to Trust s critical clinical and management functions. Assessments will include (but not limited to): current and anticipated staffing levels (sickness, overtime); psychosocial support for affected staff; effects on functions in each care group or service; damage to Trust property and shared facilities; the challenges and issues for service delivery in the short-, medium-, and long-term; financial losses Structures and processes for facilitating recovery from emergencies are also detailed in respective business continuity plans. The incident response team(s) receives priority over a business continuity management group (BCMG) and central incident support team (CIST). The nature and scale of recovery issues may warrant a simultaneous response to the critical incident or emergency and a business continuity response. If this two-pronged approach is required, the incident response team and BCMG will locate to a different incident co-ordination centre if practicable in order to maintain their separate focus, but effective methods and frequency of communications between the incident response team(s) and BCMG should be maintained (e.g. a BCMG liaison officer with the incident response team(s)). Recovery priorities may be divided sensibly between the incident response team(s) and BCMG, but this will depend on the particular circumstances of the incident and remains a matter for the Executive Directors (Associate Directors of Operations, Deputy Directors) heading each team, or the BCMG, to agree PROCUREMENT AND FINANCIAL ARRANGEMENTS IN EMERGENCIES 35.1 NHS England may require variation of the supply of goods, services and personnel NHS England has the authority to divert goods, services and personnel being supplied to one or more NHS organisations in one or more specified locations, to another NHS organisation(s) and/or in another specified location(s) NHS England may vary quantities or schedules of deliveries in order to ensure an effective incident response NHS England would exercise this power with discretion, following discussions with affected NHS organisations where circumstances permit in order to reflect overall NHS priorities. 9 October 2017 (Version 5.11) Page 42 of 113 Our Ref: CO/POL/002/073

43 35.5 Additional expenditure should be identified by Associate Directors of Operations/Heads of Service and raised with the relevant Executive Director (Deputy Director) at the earliest opportunity CRITICAL EQUIPMENT AND CONSUMABLES 36.1 The Trust endeavours to standardise critical clinical equipment where possible and has system in place to request loan equipment from other sites Refer to loss of critical equipment in the relevant Trust business continuity plan If an incident alert is cancelled or when an incident is 'stood down', all critical equipment should be checked, (decontaminated if applicable) and returned to secure storage at the earliest opportunity. Similarly any loss, damage, or malfunction of equipment should be report in line with Trust policy All stockholdings of critical/key consumables should be checked and, if necessary, replenished as soon as reasonably practicable PLAN MAINTENANCE AND REVIEW 37.1 This plan will be reviewed at least annually, unless subject to legislative, organisational or other significant change. Consultation on successive iterations may include health (including PHE) and LRF partners. Routine editorial tasks will also be undertaken by the Resilience Manager, including review of the action cards with relevant staff. A regime for checking, charging and updating equipment within incident co-ordination centres will be implemented Proposals for amendments are welcome from staff at any level within the Trust or from partners. Any such requests should be made in writing ( ) to the Resilience Manager, setting out the reason for the proposed change and any supporting documentation. All superseded hardcopy versions of this plan should be destroyed as confidential waste. The record of amendment for this plan should be completed following approval of each change and a revised version considered for immediate release DISTRIBUTION OF PLAN 38.1 This plan will be made available to all Trust services via Staff Web All copies of this plan will be formatted and distributed as pdf documents TRAINING & EXERCISES 39.1 All Trust staff with emergency response roles (and BCM roles) identified in this plan are required to attend training relevant to their function and role to ensure competency Training may include: instructional DVDs, in-house team or group training sessions and external courses. This should include appropriate training in the requirements of the Equality Act 2010 to ensure staff are aware of and are sensitive to the needs of different patient groups. Up-to-date training/skills records are required to inform the Trust s capability analysis. 9 October 2017 (Version 5.11) Page 43 of 113 Our Ref: CO/POL/002/073

44 39.3 CPFT Gold (strategic), Silver (tactical) and Bronze (operational) commanders are required to undertake training appropriate to their role Staff with a role in responding to a critical incident or emergency will be trained according to their level of need and should aspire to the relevant National Occupational Standards (NOS) for Civil Contingencies The Resilience Manager will ensure that EPRR and BCM form part of Risky Business, the Trust s mandatory training package and wider risk management training This plan will be exercised to ensure its effectiveness and validity. Where appropriate, disciplines from across the Trust as well as contractors and health/lrp partners should be involved in exercises. CPFT staff should participate in multi-agency exercises where practicable. Issues and lessons identified highlighted during exercises (and incidents) should be disseminated across the Trust as appropriate Every CPFT exercise will be given a code word. It is crucial when notifying staff or other partner organisations of any communications related to an exercise that any such message, regardless of medium, MUST be prefixed with EXERCISE e.g. EXERCISE EXERCISE EXERCISE SUNFLOWER. Exercise directing staff MUST intervene immediately if this convention is not being observed Any printed exercise material should be marked: EXERCISE- EXERCISE- EXERCISE in red bold capital letters in the header of each page to emphasise exercise play The term No Duff Gen shall be used to indicate termination of an exercise due to a real incident and/or significant business continuity disruption occurring during the same time as the exercise. Other code words that might be given during an exercise: Startex Hold Resume Safeguard Abort Endex start of exercise. suspend exercise for a period. start exercise again after a hold. real incident/message outside of exercise. early termination of exercise. end of exercise When an exercise is about to commence, the term startex is communicated to all participants. When an exercise has been concluded, the term endex shall be relayed to all relevant parties During any live exercise the safety of staff and any third party is of paramount importance and all participants should be made aware of any hazards within the exercise area and reminded of relevant safety issues The resilience annual workplan sets out the programme of EPRR (and BCM) activities, including training and exercises, for the financial year. 9 October 2017 (Version 5.11) Page 44 of 113 Our Ref: CO/POL/002/073

45 40.0 FREEDOM OF INFORMATION ACT 2000 (FOIA) AND ENVIRONMENTAL INFORMATION REGULATIONS 2004 (EIR) REQUESTS 40.1 This document is publicly available HUMAN RIGHTS 41.1 The Trust MUST uphold the Human Rights Act 1998, which requires consideration of a range of factors including the dignity of individuals receiving treatment; end-of-life considerations; prioritisation of treatments and transparency in relation to decision-making as well as individual preferences During a critical incident or emergency preservation of life has primacy, which is the core of Article 2 of the Human Rights Act 1998: everyone s right to life shall be protected by law If for any reason, an emergency necessitates restricting any Human Right, such as freedom of movement or freedom of assembly, this should be proportionate and only for the minimum duration possible. The reason for such a decision being taken should be communicated to the people affected by it and recorded accurately MONITORING COMPLIANCE WITH THIS DOCUMENT 42.1 The table below outlines the Trust s monitoring arrangements for this policy/document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored Monitoring method Individual responsible for the monitoring N/A Plan review Resilience Manager Frequency of the monitoring activity At least quarterly Group / committee which will receive the findings / monitoring report Trust Management Board (TMB) Group / committee / individual responsible for ensuring that the actions are completed Resilience Group Deputy Director of Operations REFERENCES/ BIBLIOGRAPHY The BCI Good Practice Guidelines 2013 Global Edition. A Guide to Global Good Practice in Business Continuity. Business Continuity Institute 2013 Beyond a Major Incident. Department of Health 2004 BRITISH STANDARDS INSTITUTE, ISO Societal Security - Business Continuity Management Systems Guidance BRITISH STANDARDS INSTITUTE, ISO Societal Security - Business Continuity Management Systems Requirements BRITISH STANDARDS INSTITUTE, PAS 2015: 2010 Framework for health services resilience BRITISH STANDARDS INSTITUTE, PAS 200: 2011 Crisis management. Guidance and good practice BRITISH STANDARDS INSTITUTE, PD 25111: 2010 Business continuity management - Guidance on the human aspects of business continuity BRITISH STANDARDS INSTITUTE, PD 25222: 2011 Business continuity management - Guidance on supply chain continuity 9 October 2017 (Version 5.11) Page 45 of 113 Our Ref: CO/POL/002/073

46 BRITISH STANDARDS INSTITUTE, PD 25888: 2011 Business continuity management Guidance on organizational recovery following disruptive incidents CDEM Exercises. Director s Guideline for Civil Defence Emergency Management Groups [DGL 010/09]. Version 1. New Zealand Ministry of Civil Defence & Emergency Management 2009 Central Government Arrangements for Responding to an Emergency: Concept of Operations. [Accessed 14 September 2017]. Available at Children Act 2004 Civil Contingencies Act 2004 Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 Control of Major Accident Hazards Regulations (COMAH) 2015 A guide to the Control of Major Accident Hazards Regulations (COMAH) 2015 Core Competencies Framework. The Emergency Planning Society. Issue number 2. June Corporate Manslaughter and Corporate Homicide Act 2007 Cumbria Community Risk Register Data Protection Act 1998 Developing resilient organisations across the NHS in London. NHS London 2011 Emergency Preparedness - Guidance on Part 1of the Civil Contingencies Act 2004, its associated Regulations and non-statutory arrangements. Cabinet Office 2012 Emergency Response and Recovery. Version 5. Cabinet Office 2013 Environmental Information Regulations 2004 Equality Act 2010 Essential standards of quality and safety. Care Quality Commission 2010 Evacuation and shelter guidance. Non-statutory guidance to complement Emergency preparedness and Emergency response and recovery. Cabinet Office 2014 Expectations and Indicators for Good Practice Set for Category 1 and 2 Responders. The Civil Contingencies Act (2004), its associated Regulations (2005) and guidance, the National Resilience Capabilities Programme, and emergency response and recovery. Cabinet Office 2013 Five Steps to Risk Assessment. Health & Safety Executive Framework for Managing a Major Incident. North Cumbria University Hospital NHS Trust Freedom of Information Act 2000 Furness General Hospital Major Incident Plan. Version 7.2 University Hospitals of Morecambe Bay NHS Foundation Trust 2015 Government Security Classifications. Version 1.0. Cabinet Office 2013 A guide to Pipelines Safety Regulation Guidance on Regulations. Health & Safety Executive [Accessed 14 September 2017]. Available at HBN Resilience Planning for the NHS Estate Health and Safety at Work Act 1974 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Heath and Social Care Act 2012 Health Emergency Preparedness, Resilience and Response from April Local Health Resilience Partnership: Model Concept of Operations. (Gateway Reference: 17820) Hospital and health facility emergency exercises: guidance material. World Health Organization 2010 HSG48 Reducing Error and Influencing Behaviour (1999). [Accessed 14 September 2017] Available at Humanitarian Assistance in Emergencies. Non-statutory guidance on establishing Humanitarian Assistance Centres. HM Government 2011 Human Rights Act 1998 Identifying People who are Vulnerable in a Crisis. Cabinet Office October 2017 (Version 5.11) Page 46 of 113 Our Ref: CO/POL/002/073

47 Improving Clinical Communication Using SBAR. The Health Foundation/NHS Wales 2011 Joint Doctrine: the Interoperability Framework. Edition 2.0. Joint Emergency Services Interoperability Programme (JESIP) 2016 Lockdown Guidance Protecting your NHS. Security Management Service 2009) London Mass Casualty Framework, Version 1. London Resilience 2009 Major Incident Plan. Version 1.6. East of England Ambulance Service NHS Trust 2013 Major Incident Framework. North West Ambulance Service 2012 Major Incident Procedure Manual. Eighth edition. London Emergency Services Liaison Panel Management of Health and Safety at Work Regulations 1999 Management of Public Health Incidents. Guidance on Roles and Responsibilities of NHS led Incident Management teams. Scottish Government 2011 Mass Casualty Framework. North Cumbria University Hospital NHS Trust 2014 Mass Casualty Incidents: A Framework for Planning. Department of Health 2007 Meadows-Keefe, J, Getting it all on record. Continuity Q4. Business Continuity Institute 2013 National Ambulance Service Command and Control Guidance. National Ambulance Resilience Unit 2012 National Ambulance Service Command and Control. Dynamic Decision Making Cycle. Version 2. Association of Ambulance Chief Executives 2012 National Ambulance Service Guidance for Preparing an Emergency Plan. National Ambulance Resilience Unit National Capabilities Survey. Civil Contingencies Secretariat (Cabinet Office) November 2012 National Occupational Standards for Civil Contingencies. Skills for Justice National Recovery Guidance. Cabinet Office. [Accessed 14 September 2017]. Available at National Risk Register for Civil Emergencies Cabinet Office [Accessed 26 October 2015] Available at NRR-WA_Final.pdf The New Oxford Dictionary of English. Thumb index edition. Oxford University Press 1999 (NHS England) NHS Commissioning Board Business Continuity Management Framework (service resilience) (2013) NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) NHS England 2015 (NHS England) NHS Commissioning Board Emergency Preparedness Framework 2015 (NHS England) NHS Commissioning Board, NHS CB Transition Assurance Process for Emergency Preparedness, Resilience and Response (EPRR) (NHS England) NHS Commissioning Board, NHS CB LAT Director implementation checklist for the future health arrangements for Emergency Preparedness, Resilience & Response (EPRR) NHS England/North West Ambulance Service Alerting Protocol for Cumbria incidents. November 2013 NHS Emergency Planning Guidance: Planning for the management of burn-injured patients in the event of a major incident: interim strategic national guidance. Department of Health 2011 NHS Resilience and Business Continuity Management Guidance. Department of Health 2008 NHS Standard Contract 2017/18 Service Conditions (Full Length) [Accessed 14 September 2017]. Available at: Notifications required by the Health and Social Care Act Version 6. Care Quality Commission 2013 Nursing and Midwifery Council. Information for nurses and midwives on responding to unexpected incidents or emergencies. [Accessed 14 September 2017]. Available at: 9 October 2017 (Version 5.11) Page 47 of 113 Our Ref: CO/POL/002/073

48 Pipelines Safety Regulations 1996 Preen, Jim, Business Continuity Communications Successful Incident Communications Planning with ISO Second Edition. British Standards Institute 2012 Preen, Jim, Business Continuity Exercises and Tests. Delivering Successful Exercise Programmes with ISO Second Edition. British Standards Institute 2012 Preparing For Emergencies: Guidance for Health Boards. NHS Scotland Resilience 2013 Preparing Scotland Scottish Guidance on Resilience. Philosophy, principles, structures and regulatory duties. Scottish Government July The Pitt Review Learning lessons from the floods. September Regulatory Reform (Fire Safety) Order 2005 Review of five London hospital fires and their management January 2008 February Version 1. NHS London Emergency Preparedness 2009 The role of Local Resilience Forums: a reference document. The Civil Contingencies Act (2004), its associated Regulations (2005) and guidance, the National Resilience Capabilities Programme, and emergency response and recovery. Cabinet Office 2011 [Accessed 14 September 2017] Available at: Security Vetting and Protective Marking: A Guide for Emergency Responders Sharp, John, The Route Map to Business Continuity Management. Meeting the Requirements of ISO British Standards Institute 2012 Strategic Leadership in a Crisis. Health Resilience 2012 Stuart-Black, Sarah et al, Health Emergency Planning: A Handbook for Practitioners. TSO: London 2nd Edition (2008) Useful Abbreviations. Health Protection Agency UK Civil Protection Lexicon Version Cabinet Office 2011 Wallace, M and Webber, L. The Disaster Recovery Handbook. A Step-by-Step Plan to Ensure Business Continuity and Protect Vital Operations, Facilities and Assets. Second Edition. Amacom 2011 Workplace (Health, Safety and Welfare) Regulations 1992 RELATED TRUST POLICY/PROCEDURES Business Continuity Management Policy Business Travel Policy Capacity Policy Clinical & Professional Supervision Policy Code of Conduct Communications with Media Policy Corporate and Local Induction Policy and Procedures Disclosure and Barring Service Policy Disciplinary Policy Equality and Diversity Policy Guidelines and Risk Assessment of new and expectant mother at work Health & Safety Policy/Procedure Incident and Serious Incidents that Require Investigation (SIRI) Policy Information Governance Policy Internet Access Policy Management Supervision Policy Media Relations Protocol 9 October 2017 (Version 5.11) Page 48 of 113 Our Ref: CO/POL/002/073

49 Policy for Lone Working Policy for the Recruitment of Agency Staff Policy on Prevention and Management of Violence and Aggression Policy to Promote Flexible Working Risk & Safety Strategy & Policy Security Policy Service Delivery Health & Safety Risk Assessment Policy Special Leave Policy Photography and Video Recording Policy and Procedures Preparing for a Serious Security Occurrence (Lockdown) Policy Supplementary documents to this plan: CPFT Emergency Communications Plan; CPFT Pandemic Influenza Plan; CPFT Heatwave Plan; CPFT Severe Weather Plan; CPFT Guidance for incidents involving hazardous materials; CPFT evacuation/lockdown plans. Intentionally left blank 9 October 2017 (Version 5.11) Page 49 of 113 Our Ref: CO/POL/002/073

50 APPENDIX A ESCALATION OF INCIDENTS TO NHS ENGLAND NORTH (CUMBRIA AND THE NORTH EAST) NHS Organisation/ partner agency CNE on call manager Verify information if necessary Consider possible impact on NHS Is this a potential / actual major incident No Yes No further action required Maintain watching brief Notify CNE on call Director and EPRR Manager Notify appropriate personnel Reassess situation as further information becomes available Jointly assess information received Consider/ agree action to be taken Determine if major standby or implement should be declared Activate Plan Agree who will lead response Notify appropriate personnel Establish CNE incident room is required No further action required Escalation of incident Implement local response arrangements as required Source: Adapted from NHS England CNTW. Version 1.0. November October 2017 (Version 5.11) Page 50 of 113 Our Ref: CO/POL/002/073

51 APPENDIX B NOTIFICATION OF AN INTERNAL CRITICAL INCIDENT OR EMERGENCY Start Incident Log and Personal Log Internal Incident AMBER or RED INCIDENT Threat to staff/ patients/ service users No Normal Business Hours (9am 5pm) No Notify relevant CPFT Bronze Line manager or OOH CPFT Bronze: Escalates to relevant Associate Director of Operations/Head of Service (or OOH CPFT Silver) with a situation report stating: type of incident Yes Dial 999 for emergency services, then notify line manager Line manager or senior member of staff on duty: Accounts for all staff on duty, service users, patients (contractors and visitors if applicable), maintains their safety and wellbeing, and reassures them that help is on the way Yes Notify line manager. Line manager (or OOH relevant CPFT Bronze): Assesses incident against impact assessment matrix in Table 1 (overleaf) Yes GREEN INCIDENT? Line manager (or OOH relevant CPFT Bronze) deals with incident locally, monitors carefully for possible escalations, and informs his/her line manager (OOH CPFT Silver) when the situation resolves or deteriorates. Complete an electronic incident report form No current and anticipated impact of incident any casualties any information received/given; any decisions/actions taken; any recommendations (extra help needed); confirm all these points are recorded in a personal log Relevant Associate Director of Operations or Head of Service (or OOH Silver): Escalates immediately to either Director of Operations, Chief Executive or Director of Service Improvement (or CPFT Gold). CPFT Gold: Decides whether incident warrants Major Incident DECLARED: Activate CPFT. If NOT, puts Trust at Major Incident STANDBY until further details on incident can be gathered. If Major Incident - DECLARED: Active CPFT Incident Response Plan If Major Incident STANDBY CPFT Gold: Notifies CNE 1 st on-call and relevant senior manager(s) (OOH CPFT Silver(s)) to act as tactical commander(s). CPFT Silver (s) ask(s) switchboard to contact key staff required for a teleconference (gives details) or location of CPFT incident response team(s) or incident coordination centre(s). CPFT Gold: cascades via Major Incident DECLARED: Activate CPFT Incident Response Plan to all staff. CPFT Gold: Notifies relevant senior manager(s) (OOH CPFT Silver) of Major Incident STANDBY. CPFT Silver(s) ask(s) switchboard to cascade message: Major Incident STANDBY to relevant staff required for an incident response team(s). (Team(s) remain(s) on standby until CPFT Gold issues Major Incident - STAND DOWN or Major Incident CANCELLED. CPFT Gold: Contacts incident response team(s) and switchboard to cascade Major Incident STAND DOWN. 9 October 2017 (Version 5.11) Page 51 of 113 Our Ref: CO/POL/002/073

52 Table 1: (Business continuity) incident levels Level Potential or real impact assessment Immediate action (BLUE) Negligible (GREEN) Minor disruption (AMBER) Major disruption (RED) Catastrophic disruption Limited local impact NO RISK TO PATIENT/STAFF SAFETY NO RISK TO PATIENT/STAFF SAFETY No impact on patient care service delivery Minor impact on the performance of services/departments/teams Minor Human Resources issues, but easily resolved Minor facility issues (e.g. utilities) but easily resolved Minor IT and/or telecommunications issues but able to be resolved Potential for complaints from individuals POSSIBLE OR ANTICIPATED THREAT TO PATIENT/STAFF SAFETY Potential for significant injuries or ill health Potential significant impact on care groups/department/service/team delivery Incident that is expected to last in excess of 2 hours, but potentially resolved within 8 hours Severe performance disruption of one or more care groups/departments - may require assistance/resources from one another Critical activity that MUST be fully recovered within 24 hours Potential for adverse local publicity or affecting local opinion Potential for some national media coverage The potential cost of the business continuity incident to the Trust might be in excess of 100,000 Migration of between patients/staff to other locations IMMEDIATE THREAT TO PATIENT/STAFF SAFETY Potential for one or more fatalities, or serious injury to several people Major impact on care groups/departments in one or more areas Immediate threat to patient services and/or an incident that is expected to last in excess of 8 hours (Forecast) failure of a key business application (e.g. Citrix) for in excess of 5 days Inability to work collaboratively with key partners and other stakeholders Inability to meet critical service level demands Activity would rely on external mutual aid Major specialist staff issues Recovery of activity or service MUST occur within 4 hours or less Potential for adverse national and/or local publicity of a persistant nature affecting local communities Potential for major claims which would be outside NHSLA or other insurance cover The potential cost of the business continuity incident to the Trust might be in excess of 200,000 Migration of in excess of 50 patients/staff to other locations Take any remedial action if safe to do so Report to line manager/bc lead and complete incident form Business continuity incident to be managed by individual line managers within their respective business-as-usual capabilities Relevant member of staff completes Trust incident report form Notify line manager/bc lead and/or head of service/department Business continuity incident that might require support from Trust or external specialists Relevant manager completes incident form Notify line manager or OOH relevant Bronze (Community Services, Mental Health North/South) or IT-on-call manager immediately Provide SITREP (guidance in previous flowchart at APPENDIX B) Relevant Director (Associate Director (of Operations), Deputy Director), Head of Service or authorised manager) invokes tactical and operational business continuity plans for affected areas (services or geographic locations) Notify line manager or Bronze-on-call manager immediately Provide SITREP (guidance in previous flowchart at APPENDIX B) Follow service business continuity plan 9 October 2017 (Version 5.11) Page 52 of 113 Our Ref: CO/POL/002/073

53 APPENDIX C NOTIFICATION CASCADE OF AN EXTERNAL MAJOR INCIDENT ONLY AN EXECUTIVE DIRECTOR CAN DECLARE OR STAND DOWN A MAJOR INCIDENT External Incident NHS England CNE (CCG if surge) Partner agency CNE manager/director: Alerts CPFT switchboard of Major Incident DECLARED, or Major Incident STANDBY, stating their name and contact number. Partner agency representative: Alerts CPFT switchboard of Major Incident DECLARED, or Major Incident STANDBY, stating their name and contact number. CPFT Gold: speaks to informant (authenticates caller as either from CNE (CCG if surge) or partner agency) and completes a METHANE FORM (APPENDIX D). If Major Incident - DECLARED by CNE or other local health/lrf partner If Major Incident - STANDBY by LRF partner CPFT Gold: Decides whether to issue Major Incident DECLARED: Activate CPFT to Trust staff. IF NOT, puts Trust on Major Incident STANDBY. (Record rationale for decision(s) and time in personal logbook). CPFT Gold: Decides whether to put Trust on Major Incident STANDBY. (Record rationale for decision(s) and time in personal logbook). CPFT Gold: If Major Incident DECLARED: Activate CPFT, nominates an Associate Director(s) of Operations or senior operations manager(s) (OOH CPFT Silver) to act as tactical commander(s) and inform them of the situation. CPFT Silver(s) ask(s) switchboard to contact key staff required for a teleconference (gives details) or location of incident response team(s) or incident coordination centre(s). CPFT Gold: cascades via Major Incident DECLARED: Activate CPFT Incident Response Plan to all staff CPFT Gold: Contacts an Associate Director(s) of Operations or a senior operations manager(s) (OOH Silver(s) to inform them of Major Incident STANDBY (potentially to act as tactical commander(s)) before asking CPFT switchboard to cascade message: Major Incident STANDBY to relevant staff required for an incident response team(s) team remains on standby until CPFT Gold issues Major Incident - STAND DOWN. Major Incident STAND DOWN CPFT Gold communicates this to the incident response team(s) and asks switchboard/comms lead to cascade message: Major Incident STAND DOWN to all Trust staff. 9 October 2017 (Version 5.11) Page 53 of 113 Our Ref: CO/POL/002/073

54 OFFICIAL SENSITIVE WHEN COMPLETE APPENDIX D METHANE FORM On receiving a warning message or an alert, the following information should be carefully recorded in the spaces provided PLEASE WRITE CLEARLY: Form completed by:. Message received from (name): Alerting organisation name: Landline number: Mobile phone number: Time and date call received Incident details: Major Incident status: DATE (DD/MM/YY) Organisation Standby (please tick) TIME (HH:MM) Declared Exact location of incident Type of incident Hazards present/suspected NHS England CNE (CCGs if surge) Police NWAS Access/egress arrangements/issues Number and type of casualties involved Emergency services involved RING INFORMANT BACK TO VERIFY CALL If there is any doubt about the authenticity of the call, the alert MUST be verified by calling a recognised number for the alerting body. Name: Date: (DD/MM/YY) Position: Call transferred to: (if applicable) Time:(HH:MM) OFFICIAL SENSITIVE WHEN COMPLETE 9 October 2017 (Version 5.11) Page 54 of 113 Our Ref: CO/POL/002/073

55 OFFICIAL SENSITIVE WHEN COMPLETE APPENDIX E INCIDENT SITUATION REPORT (SITREP) Note: Please complete all fields. If there is nothing to report, or the information request is not applicable, please insert NIL or N/A. Organisation: Name (completed by): Telephone number: address: Authorised for release by (name & title): Exact location of Incident Sitrep No: Date: (DD/MM/YY) Time: (HH:MM) Type of Incident (Name) Resources Deployed 1 (e.g. Ambulance, Air Ambulance, HART) Incident Casualties 2 Location P1: P2: P3 P4: Disch d Dead Pre-Hospital List Receiving Hospitals Location P1: P2: P3 Disch d Dead 3 Total at Receiving Hospitals Impact on Critical Functions 4 Capacity Issues 5a Hospital # 1 Hospital # 2 Hospital # 3 Hospital # 4 Capability Issues 5b (e.g. major trauma, burns) Impact on business as normal 6 Mutual Aid Request Made (Y/N) 7 Current / Potential Media Messages 8 OFFICIAL SENSITIVE WHEN COMPLETE 9 October 2017 (Version 5.11) Page 55 of 113 Our Ref: CO/POL/002/001

56 Notes to aid completion of SITREP 1. Resources Deployed Resources deployed at scene of incident 2. Incident Casualties: P1: Casualties requiring immediate life-saving resuscitation and/or surgery. P2: Stabilised casualties needing early surgery but delay acceptable. P3: Casualties requiring treatment but a longer delay is acceptable. P4: Expectant category confirm if invoked. 3. Fatalities in hospital: number of patients arriving at hospital and subsequently dying at/or in hospital. 4. Impact on critical functions: Implications on Category A Ambulance response times. Critical Care capacity. 5. Capacity/capability issues: This section provides a forward look for the NHS and the Department of Health. 6. Impact on business as normal: Cancellation of elective activity should be covered here. Any other service reduction as consequence of incident. 7. Mutual aid request: Confirm details of mutual aid requested, and from whom requested. 8. Media: Indicated media interest shown/reported. Provide key messages for media, also provide details of lead media contact. 9 October 2017 (Version 5.11) Page 56 of 113 Our Ref: CO/POL/002/001

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58 OFFICIAL SENSITIVE WHEN COMPLETE APPENDIX F CPFT GOLD (STRATEGIC) INCIDENT COMMANDER HANDOVER FORM Note: Please complete all fields. If there is nothing to report, or if the question is not applicable, please insert NIL or N/A. Date (DD/MM/YY): Time (HH:MM): Incident ref no. Handover name: Mobile/landline: Incident summary Takeover name: Incident location: National grid reference (if known): Major Incident Declared at: (HH:MM) By whom: Brief description of incident Who has already been informed (please tick) NHS England (CNE) Morecambe Bay CCG (lead if surge escalation) North Cumbria CCG (lead if surge escalation) NWAS NCUH UHMB Public Health England (PHE) CHOC Cumbria Police Fire Local authority Other (specify) Threats (malicious)/ hazards (non-malicious) Risks Weather on scene (if known) Current: Forecast: Is HAZMAT involved? YES (circle as appropriate) NO Decontamination of any Trust facility? YES (circle as appropriate) NO Fatalities: Injured: Level of injury Burns Critical Serious Scope of casualties (insert numbers) Emergency services involved/at scene Number taken to acute care Number to take to acute care 9 October 2017 (Version 5.11) Page 58 of 113 Our Ref: CO/POL/002/001

59 Alston Brampton Cockermouth Maryport Wigton Workington Copeland Unit CPFT community bed state Eden Unit Keswick Abbey View Millom Langdales North Langdales South Schools Affected local vulnerable facilities Residential care/nursing homes Health centres/gp practices/community pharmacies RVP/strategic holding area locations: Incident co-ordination centre issues Gold/Silver/ Bronze issues Current priorities and tasks Gold Silver Bronze Human Resources Safety and security Business continuity IT resilience (including any disaster recovery) Welfare (accommodation, water, feeding) 9 October 2017 (Version 5.11) Page 59 of 113 Our Ref: CO/POL/002/001

60 Key decision/actions undertaken so far (recorded in decision log) LRF Response rhythm Next tele/videoconference SCG meeting every hours (Multi-agency Gold if convened) Time (HH:MM) TCG meeting every hours (Multi-agency Silver if convened) Dial-in details: Is the media involved? YES (circle as appropriate) NO Trust media handling LRF media cell CNE on-call manager (1 st on-call) CNE on-call Director (2 nd on-call) Morecambe Bay CCG commissioner-on-call North Cumbria CCG commissioner-on-call NWAS contact NCUH Gold UHMB Gold CHOC contact PHE contact contact contact Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Name/telephone number: Additional comments: Handover name: Date (DD/MM/YY): Time (HH:MM): Handover complete Handover signature Takeover name: Date (DD/MM/YY): Signature certifies handover is complete. Time (HH:MM): Takeover signature Signature certifies handover is complete and the relief CPFT Gold understands fully the situation and has the necessary resources available to support the shift period. OFFICIAL SENSITIVE WHEN COMPLETE 9 October 2017 (Version 5.11) Page 60 of 113 Our Ref: CO/POL/002/001

61 APPENDIX G SUGGESTED 1 st MEETING AGENDA OF AN INCIDENT RESPONSE TEAM No Item Lead Status 1. Welcome Chair 1.1 Chair of meeting (CPFT Gold or Silver) 1.2 Check attendance of key staff including CPFT Silver, comms lead, CPFT and a loggist. 1.3 Confirm loggist is ready to record key decisions/actions start decision log 1.4 Quick introduction of attenders including any visitors 2. Incident logs Chair 2.1 Has a chronological incident log been started by CPFT Silver? 2.2 All incident staff to maintain personal logs (if relevant for role) for the duration of their involvement in the incident 3. Confirmation of a declared external (or internal) critical Chair incident/emergency state time of declaration and by whom 4. Confirmation of activation of CPFT (state time of Chair activation and by whom) 5. Response rhythm this meeting will reconvene every hours Chair CPFT Silver(s) feeding to CPFT Gold every minutes CPFT Bronze(s) feeding to CPFT Silver(s) every minutes 6. Incident brief 6.1 Nature of incident and its exact location 6.2 Scale, possible duration and current known impacts 7. Confirm Trust s strategic objectives Chair Instigate command, control, communications and co-ordination in respect of the incident. Protect the health, safety and welfare of all patients, staff, visitors and contractors at Trust facilities or using its services. Maintain effective communications with CNE and health/lrf partners. Support CNE (CCGs if surge) and health/lrf partners to preserve and protect life. Mitigate and minimise the impact of an incident. Warn and inform Trust stakeholders including the public. Identify vulnerable patients and staff. Evacuate patients and non-essential staff if applicable. Minimise the consequential disruption (impact and duration) to the Trust s critical clinical and management functions 8. Risk assessment 8.1 Requirements 9. Allocated tasks 9.1 Immediate tasks (adjourn meeting if necessary to action) 9.2 Incident + 2 hours 9.3 Resource limitations a) current; b) anticipated 9.4 Staff health, safety and welfare including any security concerns 10. Confirm communications requirements 10.1 Staff 10.2 (NHS England) CNE (CCGs if surge) and health/lrf partners 10.3 Media holding statement: Check position with CNE/LRF media cell 10.4 Digital social media who in comms team is monitoring this? 11. Confirm command and control arrangements (contact details) 11.1 Requirements and frequency of SITREPs to CNE (or CCGs if surge) 11.2 CPFT Gold(s), Silver(s), Bronze(s) for next 24 hours 11.3 CPFT Silver(s) only: CNE 1 st on-call (or CCGs commissioners-on-call) 12. Any other urgent business and close 13. (Date), time and place of next meeting 14. CHAIR: CONFIRM LOGGIST HAS RECORDED ALL KEY DECISIONS/ACTIONS. IF SATISFIED, ENTER NAME, TIME (24-HOUR) & DATE INTO DECISION LOG AND SIGN IT 9 October 2017 (Version 5.11) Page 61 of 113 Our Ref: CO/POL/002/001

62 APPENDIX H SIGNAGE TEMPLATE THIS FACILITY:.. IS CLOSED If you have been involved in an incident, or are worried that you might have been, please wait outside for assistance. If you have not been involved in an incident, please go to another facility. The nearest alternative facility is: 9 October 2017 (Version 5.11) Page 62 of 113 Our Ref: CO/POL/002/001

63 APPENDIX I DEFINITIONS For the purposes of this plan, the following terms and definitions apply. Further information on definitions and abbreviations used in the Trust s emergency planning (EPRR) (and business continuity management (BCM)) can be found in the UK Civil Protection Lexicon 10 and Joint Emergency Services Interoperability Programme (JESIP) glossary. 11 Activity A process or set of processes undertaken by the Trust (or on its behalf) that produces or supports one or more products. Assessment Examination to determine whether activities and related results conform to planned arrangements and whether these arrangements are implemented effectively and are suitable for achieving the Trust s stated objectives. Assets Anything that has value to the Trust. NOTE: There are many types of assets, including: a) information; b) software; c) physical (e.g. computer hardware); d) services; e) people, and their qualifications, skills and experience; and f) intangibles, such as reputation and image.(source: BS ISO/IEC 27000:2012, 2.4) Bronze (operational) A tier of command at which operational delivery of tasks is undertaken. Bronze is below Silver. Business as usual (BAU) - normal execution of Trust activities either by a team or an individual. Business continuity The strategic and tactical capability of the Trust to plan for and respond to incidents and business disruptions in order to continue business operations at an acceptable predefined level. Business continuity Incident (an emergency ) For the purposes of this document a business continuity incident will be defined as: an actual or impending situation that may cause injury, loss of life, destruction of property or cause the interference, loss or disruption of an organisation s normal business operations to such an extent that it poses a threat. 12 Business continuity management (BCM) The holistic management process that identifies potential threats to the Trust and provides a framework for building resilience and the capability for an effective response that safeguards the interests of its key stakeholders, reputation and value-creating activities. Business continuity management group (BCMG) A strategic-level decision-making group to address high-level business continuity and technical issues during and after the incident. Convened by the Chief Executive, or another Executive Director, to maintain the Trust s prioritised activities during disruptive challenges. Business impact analysis (BIA) The process of analysing business functions and the effect that a business disruption might have upon them. Capability - a demonstrable ability to respond to and recover from a particular threat or hazard. Casualty - someone who has sustained a physical or mental injury, or who has been killed. Category 1 responder A person or agency listed in Part 1 of Schedule 1 to the Civil Contingencies Act These are likely to be at the core of the response to most emergencies. As such, they are subject to the full range of civil protection duties in the Act. Category 2 responder A person or agency listed in Part 3 of Schedule 1 to the Civil Contingencies Act These are co-operating 10 UK Civil Protection Lexicon Version (Cabinet Office 2011) Business Continuity Institute Glossary. 9 October 2017 (Version 5.11) Page 63 of 113 Our Ref: CO/POL/002/001

64 responders who are less likely to be involved at the heart of multi-agency planning work, but will be heavily involved in preparing for incidents affecting their sectors. Central incident support team (CIST) This team will provide a focal point for all communications, co-ordination, leadership and decision-making at the tactical level during a business continuity incident/disruption (e.g. industrial action). CIST will remain separate from any (emergency) incident response team in order to maintain/recover the Trust s prioritised activities during disruptive challenges. (Morecambe Bay or North Cumbria) Clinic Commissioning Group (CCG) CCG is responsible for assessing local needs/risks and commissioning related services. It also provides a 24-hour rota to support the management of surge/operational escalation. Command The exercise of vested authority that is associated with a role (or rank) within an organisation, to give direction in order to achieve defined objectives. Community Risk Register (CRR) A register communicating the assessment of risks within a Local Resilience Forum area which is developed and published as a basis for informing local communities and directing civil protection workstreams. Competences Competences include the knowledge, judgement, skills, energy, experience and motivation required to respond adequately to the demands of one s professional responsibilities. Compliance - fulfilment of specified requirements. Consequence management Measures taken to protect public health and safety, restore essential services, and provide emergency relief to (governments, businesses, and) individuals affected by the impacts of an emergency. Control - application of authority, combined with the capability to manage resources, to achieve defined objectives. Co-ordination The integration of multi-agency efforts and available capabilities, which may be interdependent, in order to achieve defined objectives. The co-ordination function will be exercised through control arrangements, and requires that command of individual organisations personnel and assets is appropriately exercised in pursuit of the defined objectives. Critical function see prioritised activity below Critical incident An event or occurrence that disrupts, or might disrupt, an organisation s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implemented until services can return to an acceptable level. (BC) Culture - predominating attitudes and behaviours that categorize the functioning of a group or organisation. Declared major incident Emergencies that are notified by the North West Ambulance Services (NWAS), CNE or another Category 1 responder to which the Trust will be expected to respond. Dynamic risk assessment (DRA) Continuing assessment appraisal, made during an incident or emergency, of the hazards involved in, and the impact of, the response. Decontamination Removal or reduction of hazardous materials to lower the risk of further harm to victims and/or cross-contamination. Direction Collectively agreeing clear strategic aims and supporting objectives to enable prioritisation and focus of the response and recovery effort. 9 October 2017 (Version 5.11) Page 64 of 113 Our Ref: CO/POL/002/001

65 Emergency An event or situation which threatens serious damage to human welfare in a place in the UK, the environment of a place in the UK, or the security of the UK or of a place in the UK. Emergency Powers Last-resort option for responding to the most serious of emergencies where existing powers are insufficient, and additional powers are invoked under Part 2 of the Civil Contingencies Act (2004) and elsewhere. Emergency Preparedness, Resilience and Response (EPRR) The extent to which emergency planning enables the effective and efficient prevention, reduction, control and mitigation of, and response to emergencies. Environment - surroundings including plan and animal life. Exercise A simulation designed to validate the Trust s capability to manage incidents and emergencies. Specifically exercises will seek to validate training undertaken and the procedures and systems within emergency or business continuity plans. Gold (strategic) A tier of command, control and co-ordination at which policy, aim and objectives, including the overall response framework, are established and managed. Gold is a higher tier than Silver. Governance - the system by which the Trust is directed and controlled. Hazard a situation that poses a level of threat to life, health, property, or the environment. Health strategic commander NHS England Director or senior manager available to attend the local Strategic Co-ordinating Group and commit NHS resources to support the response. Sometimes referred to as NHS Gold or Health Gold. Impact - aggregate of the evaluated possible or actual consequences of a particular outcome. Incident - event or situation that requires a response from the emergency services or other responders. Incident co-ordination centre (ICC) A Trust or health facility for communications, co-ordination, leadership and decision-making during a critical incident or emergency. Incidents involving hazardous materials (HAZMAT) This might be an unforeseen event in which two or more persons are exposed to a non-radioactive, chemical substance(s). Incident response team (IRT) Senior managers and other key staff who formulate, implement and monitor the Trust s response to a critical incident or emergency. Inner cordon - surrounds the immediate area of the incident and provides security for it. It comprises of hot and warm zones. Integrated Emergency Management (IEM) This is the term used within statutory guidance to describe the multi-agency approach to emergency management, entailing six key activities: anticipation, assessment, prevention, preparation, response and recovery. Internal incidents Fire, breakdown of utilities, critical equipment failure, healthcare acquired infections, violent crime (NOTE: some of these may also be categorised as a serious untoward incident and will be managed and investigated in accordance with the Trust s Untoward Incidents/Formal Complaints/Claims Investigation Policy). Leadership - capacity to influence people, by means of personal attributes and/or behaviours, to achieve a common goal. 9 October 2017 (Version 5.11) Page 65 of 113 Our Ref: CO/POL/002/001

66 (Cumbria) Local Health Resilience Partnership (LHRP) The LHRP will ensure co-ordinated planning for emergencies impacting on health or continuity of patient services and effective engagement across local health organisations. Local Resilience Forum ((Cumbria) LRF or Cumbria Resilience Form) The process for bringing together all the Category 1 and 2 responders within a police force area for the purpose of facilitating co-operation in fulfilment of their duties under the Civil Contingencies Act. Lockdown The process where the doors leading outside or to other parts of a building are locked and people may not enter or exit at those points. Please refer to the Trust s Preparing for a Serious Security Occurrence (Lockdown) Policy. Full guidance is available in Lockdown Guidance Protecting your NHS. Security Management Service 2009). Major incident scenarios: Big Bang - a serious transport accident, explosion, or series of smaller incidents. Cloud on the Horizon - a serious threat such as a major chemical or nuclear release developing elsewhere and needing preparatory action). Headline News - public or media alarm. Rising Tide or Slow Burn(er) - event or a situation that develops into an emergency over a period of time (e.g. pandemic. Mass casualty incident An incident (or series of incidents) causing casualties on a scale that is beyond the normal resources of the emergency services. Major incident An event or situation, with a range of serious consequences, which requires special arrangements to be implemented by one or more emergency responder agencies. Monitoring Determining the status of a system, a process or an activity. Mutual aid An agreement between Category 1 and 2 responders and other organisations not covered by the Civil Contingencies Act, within the same sector or across sectors and across boundaries, to provide assistance with additional resource during an emergency. NHS England North (Cumbria and the North East ( CNE )) CNE will oversee a co-ordinated NHS response to an event or situation which may impact on NHS services, the wider community or the local population within Cumbria. Normal business hours For the purposes of incident response and recovery, this is defined for the Trust as the working period between 0900 hours 1700 hours on weekdays i.e. not weekends nor bank/public holidays. The period outside of the above definition is referred to out of hours ( OOH ). Organisations (or agencies) Public, private or voluntary agencies. Outer cordon - this designates the controlled area into which unauthorised persons are not allowed. Personal data Data which relates to a living individual or group who can be identified from the data and includes any expression of opinion about the individual and any indications of intentions in respect of the individual. (Data Protection Act 1998). Personal protective equipment (PPE) Protective clothing, helmets, goggles, or other garments designed to protect the wearer s body from injury by blunt impacts, electrical hazards, heat, chemicals, and infection. 9 October 2017 (Version 5.11) Page 66 of 113 Our Ref: CO/POL/002/001

67 Place of reasonable safety Place within a building or structure where, for a limited period of time, people have some protection from the effects of fire and smoke. Plan invocation The act of declaring that a CPFT emergency plan(s) and/or business continuity plan(s) needs to be activated to continue to deliver key services. Plan maintenance Procedures for ensuring plans are kept in readiness for emergencies and that planning documents are kept up-todate. Plan validation Measures to ensure that an emergency plan meets the purpose for which it was designed. Validation may include a range of measures including various forms of exercises and tests. Prioritised activity A service or operation the continuity of which a Category 1 responder needs to ensure, in order to meet its business objectives and/or deliver essential services. Procedure - specified way of carrying out an activity or a process. Process - set of interrelated or interacting activities, which transforms inputs into outputs. (Source: BS EN ISO 9000:2005, 3.4.1) Recovery The process of restoring, rebuilding and rehabilitating in the aftermath of an incident. Rendezvous point (RVP) A point at which all emergency services and specialists may be directed prior to deployment to the scene. Resilience - the ability at every level to detect, prevent and, if necessary, handle disruptive challenges. Resources Resources in the context of this plan mean the provision of human resources, equipment and supplies to meet the strategic, tactical and operational needs of the commanders at all three tiers, i.e. Gold, Silver, Bronze. Rest centre - building designated by a local authority for temporary accommodation of evacuees with overnight facilities if necessary. Risk - Measure of the significance of a potential emergency in terms of its assessed likelihood and impact. Risk assessment - the overall process of risk identification, analysis and evaluation. Self-presenters People who may leave the scene of an incident before cordons are put in place, either attempting to flee perceived or real danger, or not realising that they may have been involved in an incident and subsequently turn up at A&E, or a primary care or community services facility (e.g. CPFT minor injuries unit). Sensitive personal data Personal data consisting of information as to (including but not exclusively): race/ethnic origin, religious beliefs, physical or mental health and commission or alleged commission of any offence. (Data Protection Act 1998). Serious Incident(s) that Require Investigation (SIRI) A reported internal incident graded with a risk rating of 15 or above, which would have occurred on a NHS site, or elsewhere, whilst in NHS-funded or NHS-regulated care involving patients, services users, relatives or visitors, staff, or contractors working for the NHS, equipment, building or property. (Please see Trust s Incident and Serious Incidents that Require Investigation (SIRI) Policy for a fuller definition). Critical incident An event or situation when the Trust s own facilities and/or resources, or those of its neighbours, are overwhelmed. 9 October 2017 (Version 5.11) Page 67 of 113 Our Ref: CO/POL/002/001

68 Silver (tactical) A tier of command, control and co-ordination at the tactical level, where the response to the incident is actually managed. Silver is the tier below Gold but above Bronze. Stakeholder - those with a vested interest in an organisation s achievements. Threat - intent to, or incident that may inflict harm or loss on a(nother) person(s). Threat level - these are designed to give a broad indication of the likelihood of a terrorist attack. Timescales For the purposes of Trust emergency planning (EPRR) and business continuity management (BCM): Short term Medium term Long term = up to 48 hours = up to 7 operational days = over 7 operational days Triage The process of determining the priority of casualties (patients ) treatment based on the severity of their condition. Unusual incident This may include a localised weather event (i.e. an incident that does not trigger a declared major incident, but CNE will assess the situation and decide upon an appropriate response). Vulnerable person Cabinet Office (2008) defines vulnerable people as those: that are less able to help themselves in the circumstances of an emergency, hence planning should note survivors/victims may require external assistance to become safe. Worried well Members of the public who may be near to an incident when it happens or have heard about it from another source and are worried that they may have been affected by the incident, or consider themselves likely to need medical intervention. Intentionally left blank 9 October 2017 (Version 5.11) Page 68 of 113 Our Ref: CO/POL/002/001

69 APPENDIX J DECISION-MAKING MODEL (JOINT DECISION MODEL) & STEEPLE ANALYSIS The Association of Chief Police Officers (ACPO) national decision-making model can be used as a framework for decision-making throughout the course of an incident. The model is cyclical where each step logically follows another and allows for continued reassessment of the situation or incident enabling previous steps to be revisited. STEEPLE ANALYSIS SOCIAL TECHNICAL ENVIRONMENTAL ETHICAL POLITICAL LEGAL ECONOMIC 9 October 2017 (Version 5.11) Page 69 of 113 Our Ref: CO/POL/002/001